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Maiwall R, Piano S, Singh V, Caraceni P, Alessandria C, Fernandez J, Soares EC, Kim DJ, Kim SE, Marino M, Vorobioff J, Ribeiro Barea RDC, Merli M, Elkrief L, Vargas V, Krag A, Singh SP, Lesmana LA, Toledo C, Marciano S, Verhelst X, Wong F, Intagliata N, Rabinowich L, Colombato L, Kim SG, Gerbes A, Durand F, Roblero JP, Bhamidimarri KR, Maevskaya M, Fassio E, Kim HS, Hwang JS, Gines P, Bruns T, Gadano A, Angeli P, Sarin SK. Determinants of clinical response to empirical antibiotic treatment in patients with cirrhosis and bacterial and fungal infections-Results from the ICA "Global Study" (EABCIR-Global Study). Hepatology 2024; 79:1019-1032. [PMID: 38047909 DOI: 10.1097/hep.0000000000000653] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2022] [Accepted: 06/30/2023] [Indexed: 12/05/2023]
Abstract
BACKGROUND The administration of an appropriate empirical antibiotic treatment is essential in cirrhosis and severe bacterial infections. We aimed to investigate the predictors of clinical response of empirical antibiotic treatment in a prospective cohort of patients with cirrhosis and bacterial and fungal infections included in the International Club of Ascites "Global Study." METHODS Patients hospitalized with cirrhosis and bacterial/fungal infection were prospectively enrolled at 46 centers. Clinical response to antibiotic treatment was defined according to changes in markers of infection/inflammation, vital signs, improvement of organ failure, and results of cultures. RESULTS From October 2015 to September 2016, 1302 patients were included at 46 centers. A clinical response was achieved in only 61% of cases. Independent predictors of lack of clinical response to empirical treatment were C-reactive protein (OR = 1.16; 95% CI = 1.02-1.31), blood leukocyte count (OR = 1.39;95% CI = 1.09-1.77), serum albumin (OR = 0.70; 95% CI = 0.55-0.88), nosocomial infections (OR = 1.96; 95% CI = 1.20-2.38), pneumonia (OR = 1.75; 95% CI = 1.22-2.53), and ineffective treatment according to antibiotic susceptibility test (OR = 5.32; 95% CI = 3.47-8.57). Patients with a lack of clinical response to first-line antibiotic treatment had a significantly lower resolution rate of infections (55% vs. 96%; p < 0.001), a higher incidence of second infections (29% vs. 15%; p < 0.001), shock (35% vs. 7%; p < 0.001) and new organ failures (52% vs. 19 %; p < 0.001) than responders. Clinical response to empirical treatment was an independent predictor of 28-day survival ( subdistribution = 0.20; 95% CI = 0.14-0.27). CONCLUSIONS Four out of 10 patients with cirrhosis do not respond to the first-line antibiotic therapy, leading to lower resolution of infections and higher mortality. Broader-spectrum antibiotics and strategies targeting systemic inflammation may improve prognosis in patients with a high degree of inflammation, low serum albumin levels, and severe liver impairment.
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Affiliation(s)
- Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Barcelona, Spain
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Elza Cotrim Soares
- Gastroenterology Division, Medicine Department, Faculty of Medical Sciences, University of Campinas (UNICAMP). Campinas, São Paulo, Brazil
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, South Korea
| | - Sung Eun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Sacred Heart Hospital, College of Medicine, Hallym University, Anyang city, Republic of Korea
| | - Monica Marino
- Liver Unit, Hospital Dr. Carlos B. Udaondo, Buenos Aires, Argentina
| | | | | | - Manuela Merli
- Gastroenterology and Hepatology Unit, Department of Translational and Precision Medicine, Sapienza University of Rome, Rome, Italy
| | - Laure Elkrief
- Service de Transplantation, Service d'Hépato-gastroentérologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Victor Vargas
- Liver Unit, Department of Internal Medicine, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, CIBERehd, Barcelona. Spain
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | | | | | - Claudio Toledo
- Gastroenterology Unit, Hospital Valdivia, Universidad Austral de Chile, Valdivia, Chile
| | - Sebastian Marciano
- Liver Unit and Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Nicolas Intagliata
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Liane Rabinowich
- Liver Unit, Department of Gastroenterology, Tel-Aviv Medical Center and Tel-Aviv University, Tel-Aviv, Israel
| | - Luis Colombato
- Gastroenterology Department, Buenos Aires British Hospital, Argentine Catholic University (UCA), Buenos Aires, Argentina
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Alexander Gerbes
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU Munich, Germany
| | - Francois Durand
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, University Paris Diderot, Paris, France
| | - Juan Pablo Roblero
- Departamento de Medicina, Universidad de Chile Campus Centro, Hospital Clínico San Borja Arriarán, Santiago, Chile
| | | | | | - Eduardo Fassio
- Liver Unit, Hospital Nacional Prof. Alejandro Posadas, El Palomar, Buenos Aires, Argentina
| | - Hyoung Su Kim
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Jae Seok Hwang
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Korea
| | - Pere Gines
- Liver ICU, Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain
- Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Barcelona, Spain
| | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Jena, Germany
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Adrian Gadano
- Liver Unit and Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
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Lange CM, Trebicka J, Gerbes A, Canbay A, Geier A, Merle U, Peck-Radosavljevic M, Tacke F, Vogelmann T, Theis S, Heinze H, Zipprich A. Limited access to liver transplantation and TIPS despite high mortality, healthcare resource use and costs of cirrhosis in Germany. Liver Int 2023; 43:2503-2512. [PMID: 37602977 DOI: 10.1111/liv.15688] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Revised: 06/27/2023] [Accepted: 07/24/2023] [Indexed: 08/22/2023]
Abstract
BACKGROUND AND AIMS Data on number of patients with cirrhosis in Germany are limited. We therefore aimed to estimate prevalence, comorbidities, mortality, utilization of healthcare resources and costs of patients with cirrhosis and incidence of decompensation of cirrhosis in Germany. METHODS This longitudinal observational study was based on an anonymized representative claims database including 4.9 million persons insured by a statutory health insurance (SHI) between 2015-2020. Patients with decompensated and compensated cirrhosis were selected via diagnostic ICD codes and followed for 2 years. RESULTS Prevalence of cirrhosis in 2015 was 250/100 000, resulting in 201 747 (95% CI: 197 540-206 040) patients extrapolated to the German population. Out of all patients with compensated cirrhosis in 2015 who did not deceased, 16.0% developed a decompensation within 3 years. Overall, 978 patients (Ø-age: 68 years; 60% male) were included in the decompensated, and 5135 patients (Ø-age: 66 years; 59% male) in the compensated cirrhosis cohort. Patients with decompensated cirrhosis had a higher burden of comorbidities (Charlson Comorbidity Index 7.3 vs. 4.4) and 3 times higher costs per quarter (7172 € vs. 2213 €) than patients with compensated cirrhosis. 1-year mortality after decompensation was 51% compared to 8% in compensated cirrhosis. Of note, only few patients with decompensated cirrhosis received a liver transplantation or transjugular intrahepatic portosystemic shunts (TIPS) (1% and 5%). CONCLUSION Patients with cirrhosis have a high healthcare burden in especially decompensated stage. Accordingly, 1-year mortality of decompensated cirrhosis in Germany is high. Despite high health resource utilization, only few patients have access to liver transplantation or TIPS.
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Affiliation(s)
- Christian M Lange
- Department of Medicine II, University Hospital, LMU, Munich, Germany
| | - Jonel Trebicka
- Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Alexander Gerbes
- Department of Medicine II, University Hospital, LMU, Munich, Germany
| | - Ali Canbay
- Department of Internal Medicine, University Hospital of the Knappschaftskrankenhauses Bochum, Bochum, Germany
| | - Andreas Geier
- Division of Hepatology, Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Uta Merle
- Internal Medicine IV Gastroenterology, Heidelberg University Hospital, Heidelberg, Germany
| | | | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité - Universitätsmedizin Berlin, Campus Virchow-Klinikum (CVK), Campus Charité Mitte (CCM), Berlin, Germany
| | | | | | | | - Alexander Zipprich
- Department of Internal Medicine IV (Gastroenterology, Hepatology, Infectiology), University Hospital Jena, Jena, Germany
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3
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Gu W, Zeleke Y, Hortlik H, Schaaf L, Uschner FE, Schulz M, Tischendorf M, Peiffer KH, Brol MJ, Kimmann M, Vogl T, Köhler M, Meyer C, Gerbes A, Rössle M, Laleman W, Zipprich A, Steib C, Praktiknjo M, Trebicka J. Use and outcome of TIPS in hospitalized patients in Germany: A Nationwide study (2007-2018). Hepatol Commun 2023; 7:e0237. [PMID: 37708430 PMCID: PMC10503680 DOI: 10.1097/hc9.0000000000000237] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Accepted: 06/14/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND The number of complications in patients admitted for cirrhosis has increased over time. Portal hypertension is the driver of many complications of cirrhosis. TIPS placement is the most effective treatment of portal hypertension. The aim of this study was to analyze the use and impact of TIPS placement in the last decade in a nationwide study in Germany. METHODS We analyzed 14,598 admissions of patients for TIPS insertions in Germany from 2007 to 2018 using the DRG system, 12,877 out of 2,000,765 total admissions of patients with cirrhosis. All diagnoses and procedures were coded according to ICD-10-CM and OPS codes. The data were analyzed, focusing on the number of admissions and in-hospital mortality. RESULTS The number of TIPS placements increased over the last decade. In-hospital mortality of cirrhotic patients with TIPS decreased when it was placed for severe bleeding (15.2% [TIPS] vs. 19.5% [endoscopy treatment]), ascites (8.7% [TIPS] vs. 14.4% [paracentesis]), and hepatorenal syndrome (HRS) (17.1% [TIPS] vs. 43.3% [no-TIPS]). In the case of bleeding, TIPS significantly decreased in-hospital mortality and also in ascites and HRS. During hospitalization, 22.6% admissions of patients with TIPS insertion showed HE. However, in-hospital mortality in patients admitted with HE grades 1 or 2 and TIPS was lower than in patients without TIPS. In the logistic regression, a higher HE grade(3 and 4), infection, and circulatory disease were found to be independently associated with in-hospital mortality in patients with TIPS insertion. CONCLUSION Our nationwide study demonstrates that TIPS insertion is increasingly used in Germany. TIPS improves outcomes, especially in patients with ascites and HRS, regardless of lower HE grades, while higher HE grades, infection, and circulatory diseases seem to be associated with risk of in-hospital mortality.
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Affiliation(s)
- Wenyi Gu
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Yasmin Zeleke
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Hannah Hortlik
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Louisa Schaaf
- Department of Internal Medicine I, University Hospital Frankfurt, Goethe University Frankfurt, Frankfurt am Main, Germany
| | - Frank E. Uschner
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Martin Schulz
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Michael Tischendorf
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Kai-Henrik Peiffer
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | | | - Markus Kimmann
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Thomas Vogl
- Institute of Diagnostic and Interventional Radiology, University Hospital Frankfurt, Frankfurt am Main, Germany
| | - Michael Köhler
- Clinic for Radiology, University Hospital Muenster, Muenster, Germany
| | - Carsten Meyer
- Clinic for Radiology, University Hospital Bonn, Bonn, Germany
| | - Alexander Gerbes
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Martin Rössle
- Department of Internal Medicine II, Faculty of Medicine, Medical Centre University of Freiburg, University of Freiburg, Freiburg, Germany
| | - Wim Laleman
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- Department of Gastroenterology and Hepatology, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Alexander Zipprich
- Department of Internal Medicine IV (Gastroenterology, Hepatology and Infectious Diseases), Jena University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Christian Steib
- Department of Medicine II, University Clinic Munich LMU, Munich, Germany
| | - Michael Praktiknjo
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
| | - Jonel Trebicka
- Department of Internal Medicine B, University Hospital Muenster, Muenster, Germany
- European Foundation for Study of Chronic Liver Failure, Barcelona, Spain
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
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4
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Grove JI, Stephens C, Lucena MI, Andrade RJ, Weber S, Gerbes A, Bjornsson ES, Stirnimann G, Daly AK, Hackl M, Khamina-Kotisch K, Marin JJG, Monte MJ, Paciga SA, Lingaya M, Forootan SS, Goldring CEP, Poetz O, Lombaard R, Stege A, Bjorrnsson HK, Robles-Diaz M, Li D, Tran TDB, Ramaiah SK, Samodelov SL, Kullak-Ublick GA, Aithal GP. Study design for development of novel safety biomarkers of drug-induced liver injury by the translational safety biomarker pipeline (TransBioLine) consortium: a study protocol for a nested case-control study. Diagn Progn Res 2023; 7:18. [PMID: 37697410 PMCID: PMC10496294 DOI: 10.1186/s41512-023-00155-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2023] [Accepted: 08/08/2023] [Indexed: 09/13/2023] Open
Abstract
A lack of biomarkers that detect drug-induced liver injury (DILI) accurately continues to hinder early- and late-stage drug development and remains a challenge in clinical practice. The Innovative Medicines Initiative's TransBioLine consortium comprising academic and industry partners is developing a prospective repository of deeply phenotyped cases and controls with biological samples during liver injury progression to facilitate biomarker discovery, evaluation, validation and qualification.In a nested case-control design, patients who meet one of these criteria, alanine transaminase (ALT) ≥ 5 × the upper limit of normal (ULN), alkaline phosphatase ≥ 2 × ULN or ALT ≥ 3 ULN with total bilirubin > 2 × ULN, are enrolled. After completed clinical investigations, Roussel Uclaf Causality Assessment and expert panel review are used to adjudicate episodes as DILI or alternative liver diseases (acute non-DILI controls). Two blood samples are taken: at recruitment and follow-up. Sample size is as follows: 300 cases of DILI and 130 acute non-DILI controls. Additional cross-sectional cohorts (1 visit) are as follows: Healthy volunteers (n = 120), controls with chronic alcohol-related or non-alcoholic fatty liver disease (n = 100 each) and patients with psoriasis or rheumatoid arthritis (n = 100, 50 treated with methotrexate) are enrolled. Candidate biomarkers prioritised for evaluation include osteopontin, glutamate dehydrogenase, cytokeratin-18 (full length and caspase cleaved), macrophage-colony-stimulating factor 1 receptor and high mobility group protein B1 as well as bile acids, sphingolipids and microRNAs. The TransBioLine project is enabling biomarker discovery and validation that could improve detection, diagnostic accuracy and prognostication of DILI in premarketing clinical trials and for clinical healthcare application.
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Affiliation(s)
- Jane I Grove
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Camilla Stephens
- Servicios de Aparato Digestivo Y Farmacologia Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA Plataforma Bionand, Hospital Universitario Virgen de La Victoria, Universidad de Málaga, Malaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas Y Digestivas (CIBERehd), Madrid, Spain
| | - M Isabel Lucena
- Servicios de Aparato Digestivo Y Farmacologia Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA Plataforma Bionand, Hospital Universitario Virgen de La Victoria, Universidad de Málaga, Malaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas Y Digestivas (CIBERehd), Madrid, Spain
| | - Raúl J Andrade
- Servicios de Aparato Digestivo Y Farmacologia Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA Plataforma Bionand, Hospital Universitario Virgen de La Victoria, Universidad de Málaga, Malaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas Y Digestivas (CIBERehd), Madrid, Spain
| | - Sabine Weber
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Alexander Gerbes
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Einar S Bjornsson
- Department of Gastroenterology, Landspitali University Hospital Reykjavik, University of Iceland, Reykjavík, Iceland
- Faculty of Medicine, University of Iceland, Reykjavík, Iceland
| | - Guido Stirnimann
- University Clinic for Visceral Surgery and Medicine, University Hospital Inselspital and University of Bern, Bern, Switzerland
| | - Ann K Daly
- Translational and Clinical Research Institute, Newcastle University, Newcastle Upon Tyne, NE2 4HH, UK
| | | | | | - Jose J G Marin
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas Y Digestivas (CIBERehd), Madrid, Spain
- Experimental Hepatology and Drug Targeting (HEVEPHARM), Institute of Biomedical Research of Salamanca (IBSAL), University of Salamanca, Salamanca, Spain
| | - Maria J Monte
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas Y Digestivas (CIBERehd), Madrid, Spain
- Experimental Hepatology and Drug Targeting (HEVEPHARM), Institute of Biomedical Research of Salamanca (IBSAL), University of Salamanca, Salamanca, Spain
| | - Sara A Paciga
- Worldwide Research Development and Medical, Pfizer, NY, USA
| | - Melanie Lingaya
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Shiva S Forootan
- Centre for Drug Safety Science, University of Liverpool, Liverpool, UK
| | | | | | - Rudolf Lombaard
- ABX-CRO Advanced Pharmaceutical Services, Forschungsgesellschaft mbH, Cape Town, 7441, South Africa
| | - Alexandra Stege
- Charité-Universitätsmedizin Berlin, Central Biobank Charité (ZeBanC), Berlin, Germany
| | - Helgi K Bjorrnsson
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mercedes Robles-Diaz
- Servicios de Aparato Digestivo Y Farmacologia Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA Plataforma Bionand, Hospital Universitario Virgen de La Victoria, Universidad de Málaga, Malaga, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas Y Digestivas (CIBERehd), Madrid, Spain
| | - Dingzhou Li
- Worldwide Research Development and Medical, Pfizer, NY, USA
| | | | | | - Sophia L Samodelov
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, 8006, Zurich, Switzerland
| | - Gerd A Kullak-Ublick
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, 8006, Zurich, Switzerland
- Mechanistic Safety, CMO & Patient Safety, Global Drug Development, Novartis Pharma, 4056, Basel, Switzerland
| | - Guruprasad P Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, University of Nottingham, Nottingham, NG7 2UH, UK.
- NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK.
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5
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Andrade RJ, Aithal GP, de Boer YS, Liberal R, Gerbes A, Regev A, Terziroli Beretta-Piccoli B, Schramm C, Kleiner DE, De Martin E, Kullak-Ublick GA, Stirnimann G, Devarbhavi H, Vierling JM, Manns MP, Sebode M, Londoño MC, Avigan M, Robles-Diaz M, García-Cortes M, Atallah E, Heneghan M, Chalasani N, Trivedi PJ, Hayashi PH, Taubert R, Fontana RJ, Weber S, Oo YH, Zen Y, Licata A, Lucena MI, Mieli-Vergani G, Vergani D, Björnsson ES. Nomenclature, diagnosis and management of drug-induced autoimmune-like hepatitis (DI-ALH): An expert opinion meeting report. J Hepatol 2023; 79:853-866. [PMID: 37164270 PMCID: PMC10735171 DOI: 10.1016/j.jhep.2023.04.033] [Citation(s) in RCA: 20] [Impact Index Per Article: 20.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Revised: 04/26/2023] [Accepted: 04/29/2023] [Indexed: 05/12/2023]
Abstract
Drug-induced liver injury (DILI) can mimic almost all other liver disorders. A phenotype increasingly ascribed to drugs is autoimmune-like hepatitis (ALH). This article summarises the major topics discussed at a joint International Conference held between the Drug-Induced Liver Injury consortium and the International Autoimmune Hepatitis Group. DI-ALH is a liver injury with laboratory and/or histological features that may be indistinguishable from those of autoimmune hepatitis (AIH). Previous studies have revealed that patients with DI-ALH and those with idiopathic AIH have very similar clinical, biochemical, immunological and histological features. Differentiating DI-ALH from AIH is important as patients with DI-ALH rarely require long-term immunosuppression and the condition often resolves spontaneously after withdrawal of the implicated drug, whereas patients with AIH mostly require long-term immunosuppression. Therefore, revision of the diagnosis on long-term follow-up may be necessary in some cases. More than 40 different drugs including nitrofurantoin, methyldopa, hydralazine, minocycline, infliximab, herbal and dietary supplements (such as Khat and Tinospora cordifolia) have been implicated in DI-ALH. Understanding of DI-ALH is limited by the lack of specific markers of the disease that could allow for a precise diagnosis, while there is similarly no single feature which is diagnostic of AIH. We propose a management algorithm for patients with liver injury and an autoimmune phenotype. There is an urgent need to prospectively evaluate patients with DI-ALH systematically to enable definitive characterisation of this condition.
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Affiliation(s)
- Raúl J Andrade
- Servicio Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA_Plataforma Bionand, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain.
| | - Guruprasad P Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Ynto S de Boer
- Department of Gastroenterology and Hepatology, Amsterdam University Medical Centers, VU University Medical Center, Amsterdam, Netherlands
| | - Rodrigo Liberal
- Gastroenterology Department, Centro Hospitalar Universitário de São João, Porto, Portugal; Faculty of Medicine of the University of Porto, Porto, Portugal
| | | | - Arie Regev
- Eli Lilly and Company, Indianapolis, IN, USA
| | | | - Christoph Schramm
- Department of Medicine, University Medical Center Hamburg-Eppendorf. Hamburg Center for Translational Immunology. Martin Zeitz Center for Rare Diseases, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - David E Kleiner
- Laboratory of Pathology, National Cancer Institute, National Institutes of Health, Bethesda, USA
| | - Eleonora De Martin
- APHP, Hôpital Paul Brousse, Centre Hépato-Biliaire, INSERM Unit 1193, FHU Hepatinov, Villejuif, France
| | - Gerd A Kullak-Ublick
- Department of Clinical Pharmacology and Toxicology, University Hospital Zurich, University of Zurich, Zurich, Switzerland; Mechanistic Safety, Global Drug Development, Novartis, Basel, Switzerland
| | - Guido Stirnimann
- Department of Visceral Surgery and Medicine, Inselspital University Hospital and University of Bern, Bern, Switzerland
| | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St. John's Medical College Hospital, Bangalore, India
| | - John M Vierling
- Departments of Medicine and Surgery, Section of Gastroenterology and Hepatology and Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas, United States
| | - Michael P Manns
- Hannover Medical School, Centre of ERN RARE-LIVER, Hannover, Germany
| | - Marcial Sebode
- Department of Internal Medicine, University Medical Center Hamburg-Eppendorf, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hamburg, Germany
| | - Maria Carlota Londoño
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Liver Unit, Hospital Clínic de Barcelona, Health Care Provider of the European Reference Network on Rare Liver Disorders (ERN-Liver), Institut d' Investigacions Biomédiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Mark Avigan
- Center for Drug Evaluation and Research, Office of Surveillance and Epidemiology, US Food and Drug Administration, Silver Spring, Maryland, USA
| | - Mercedes Robles-Diaz
- Servicio Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA_Plataforma Bionand, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Miren García-Cortes
- Servicio Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA_Plataforma Bionand, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain
| | - Edmond Atallah
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of Medicine, NIHR Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | | | - Naga Chalasani
- University School of Medicine & Indiana University Health, Indianapolis, Indiana, USA
| | - Palak J Trivedi
- NIHR Birmingham BRC, Institute of Immunology and Immunotherapy, Centre for Liver and Gastrointestinal Research, Liver Unit, University Hospitals Birmingham National Health Service Foundation Trust Queen Elizabeth, Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Paul H Hayashi
- Division of Hepatology and Nutrition, Food and Drug Administration, Silver Spring, Maryland, USA
| | - Richard Taubert
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, European Reference Network on Hepatological Diseases (ERN RARE-LIVER), Hannover, Germany
| | - Robert J Fontana
- Division of Gastroenterology and Hepatology, University of Michigan Medical School, Ann Arbor, MI, United States
| | - Sabine Weber
- Department of Medicine II, LMU Klinikum Munich, Munich, Germany
| | - Ye Htun Oo
- Center for Liver and Gastro Research & National Institute of Health Research Birmingham Biomedical Research Centre, University of Birmingham, Centre for Rare Disease and ERN Rare Liver Centre, Liver Transplant and Hepatobiliary Unit, University Hospital Birmingham NHS Foundation Trust, UK
| | - Yoh Zen
- Institute of Liver Studies, King's College Hospital, London SE5 9RS, UK
| | - Anna Licata
- Medicina Interna ed Epatologia, Università degli Studi di Palermo, Palermo, Italy
| | - M Isabel Lucena
- Servicio Aparato Digestivo and Servicio de Farmacología Clínica, Instituto de Investigación Biomédica de Málaga-IBIMA_Plataforma Bionand, Hospital Universitario Virgen de la Victoria, Universidad de Málaga, Málaga, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Madrid, Spain; Platform ISCiii for Clinical Research and Clinical Trials SCReN UICEC- IBIMA, Málaga, Spain.
| | - Giorgina Mieli-Vergani
- MowatLabs, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, United Kingdom
| | - Diego Vergani
- MowatLabs, Faculty of Life Sciences and Medicine, King's College London, King's College Hospital, London, United Kingdom
| | - Einar S Björnsson
- Faculty of Medicine, University of Iceland, Department of Gastroenterology and Hepatology, Landspitali University Hospital, Reykjavik, Iceland
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Björnsson ES, Stephens C, Atallah E, Robles‐Diaz M, Alvarez‐Alvarez I, Gerbes A, Weber S, Stirnimann G, Kullak‐Ublick G, Cortez‐Pinto H, Grove JI, Lucena MI, Andrade RJ, Aithal GP. A new framework for advancing in drug-induced liver injury research. The Prospective European DILI Registry. Liver Int 2023; 43:115-126. [PMID: 35899490 PMCID: PMC7614006 DOI: 10.1111/liv.15378] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 07/10/2022] [Accepted: 07/27/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND & AIMS No multi-national prospective study of drug-induced liver injury (DILI) has originated in Europe. The design of a prospective European DILI registry, clinical features and short-term outcomes of the cases and controls is reported. METHODS Patients with suspected DILI were prospectively enrolled in the United Kingdom, Spain, Germany, Switzerland, Portugal and Iceland, 2016-2021. DILI cases or non-DILI acute liver injury controls following causality assessment were enrolled. RESULTS Of 446 adjudicated patients, 246 DILI patients and 100 had acute liver injury due to other aetiologies, mostly autoimmune hepatitis (n = 42) and viral hepatitis (n = 34). DILI patients (mean age 56 years), 57% women, 60% with jaundice and 3.6% had pre-existing liver disease. DILI cases and non-DILI acute liver injury controls had similar demographics, clinical features and outcomes. A single agent was implicated in 199 (81%) DILI cases. Amoxicillin-clavulanate, flucloxacillin, atorvastatin, nivolumab/ipilimumab, infliximab and nitrofurantoin were the most commonly implicated drugs. Multiple conventional medications were implicated in 37 (15%) and 18 cases were caused by herbal and dietary supplements. The most common single causative drug classes were antibacterials (40%) and antineoplastic/immunomodulating agents (27%). Overall, 13 (5.3%) had drug-induced autoimmune-like hepatitis due to nitrofurantoin, methyldopa, infliximab, methylprednisolone and minocycline. Only six (2.4%) DILI patients died (50% had liver-related death), and another six received liver transplantation. CONCLUSIONS In this first multi-national European prospective DILI Registry study, antibacterials were the most commonly implicated medications, whereas antineoplastic and immunomodulating agents accounted for higher proportion of DILI than previously described. This European initiative provides an important opportunity to advance the study on DILI.
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Affiliation(s)
- Einar S. Björnsson
- Faculty of MedicineUniversity of IcelandReykjavíkIceland
- Department of GastroenterologyLandspitali University Hospital ReykjavikReykjavíkIceland
| | - Camilla Stephens
- Servicios de Aparato Digestivo y Farmacología ClínicaHospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina‐IBIMA Plataforma BIONAND, Universidad de MálagaMálagaSpain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)MadridSpain
| | - Edmond Atallah
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of MedicineUniversity of NottinghamNottinghamUK
- NIHR Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
| | - Mercedes Robles‐Diaz
- Servicios de Aparato Digestivo y Farmacología ClínicaHospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina‐IBIMA Plataforma BIONAND, Universidad de MálagaMálagaSpain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)MadridSpain
| | - Ismael Alvarez‐Alvarez
- Servicios de Aparato Digestivo y Farmacología ClínicaHospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina‐IBIMA Plataforma BIONAND, Universidad de MálagaMálagaSpain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)MadridSpain
| | | | - Sabine Weber
- Department of Medicine IILMU Klinikum MunichMunichGermany
| | - Guido Stirnimann
- Department of Visceral Surgery and MedicineInselspital University Hospital and University of BernBernSwitzerland
| | - Gerd Kullak‐Ublick
- Department of Clinical Pharmacology and ToxicologyUniversity Hospital Zurich, University of ZurichZurichSwitzerland
| | - Helena Cortez‐Pinto
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina de LisboaUniversidade de Lisboa, Centro Hospitalar Lisboa Norte, HSMLisbonPortugal
| | - Jane I. Grove
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of MedicineUniversity of NottinghamNottinghamUK
- NIHR Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
| | - M. Isabel Lucena
- Servicios de Aparato Digestivo y Farmacología ClínicaHospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina‐IBIMA Plataforma BIONAND, Universidad de MálagaMálagaSpain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)MadridSpain
| | - Raul J. Andrade
- Servicios de Aparato Digestivo y Farmacología ClínicaHospital Universitario Virgen de la Victoria, Instituto de Investigación Biomédica de Málaga y Plataforma en Nanomedicina‐IBIMA Plataforma BIONAND, Universidad de MálagaMálagaSpain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)MadridSpain
| | - Guruprasad P. Aithal
- Nottingham Digestive Diseases Centre, Translational Medical Sciences, School of MedicineUniversity of NottinghamNottinghamUK
- NIHR Nottingham Biomedical Research CentreNottingham University Hospitals NHS Trust and the University of NottinghamNottinghamUK
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Trebicka J, Fernandez J, Papp M, Caraceni P, Laleman W, Gambino C, Giovo I, Uschner FE, Jansen C, Jimenez C, Mookerjee R, Gustot T, Albillos A, Bañares R, Jarcuska P, Steib C, Reiberger T, Acevedo J, Gatti P, Shawcross DL, Zeuzem S, Zipprich A, Piano S, Berg T, Bruns T, Danielsen KV, Coenraad M, Merli M, Stauber R, Zoller H, Ramos JP, Solé C, Soriano G, de Gottardi A, Gronbaek H, Saliba F, Trautwein C, Kani HT, Francque S, Ryder S, Nahon P, Romero-Gomez M, Van Vlierberghe H, Francoz C, Manns M, Garcia-Lopez E, Tufoni M, Amoros A, Pavesi M, Sanchez C, Praktiknjo M, Curto A, Pitarch C, Putignano A, Moreno E, Bernal W, Aguilar F, Clària J, Ponzo P, Vitalis Z, Zaccherini G, Balogh B, Gerbes A, Vargas V, Alessandria C, Bernardi M, Ginès P, Moreau R, Angeli P, Jalan R, Arroyo V, Semela D, Elkrief L, Elsharkawy A, Tornai T, Tornai I, Altorjay I, Antognoli A, Baldassarre M, Gagliardi M, Bertoli E, Mareso S, Brocca A, Campion D, Saracco GM, Rizzo M, Lehmann J, Pohlmann A, Brol MJ, Chang J, Schierwagen R, Solà E, Amari N, Rodriguez M, Nevens F, Clemente A, Janicko M, Markwardt D, Mandorfer M, Welsch C, Welzel TM, Ciraci E, Patel V, Ripoll C, Herber A, Horn P, Bendtsen F, Gluud LL, Schaapman J, Riggio O, Rainer F, Moritz JT, Mesquita M, Alvarado-Tapias E, Akpata O, Aamann L, Samuel D, Tresson S, Strnad P, Amathieu R, Simón-Talero M, Smits F, van den Ende N, Martinez J, Garcia R, Rupprechter H, Engelmann C, Özdogan OC. PREDICT identifies precipitating events associated with the clinical course of acutely decompensated cirrhosis. J Hepatol 2021; 74:1097-1108. [PMID: 33227350 DOI: 10.1016/j.jhep.2020.11.019] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 11/10/2020] [Accepted: 11/10/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Acute decompensation (AD) of cirrhosis may present without acute-on-chronic liver failure (ACLF) (AD-No ACLF), or with ACLF (AD-ACLF), defined by organ failure(s). Herein, we aimed to analyze and characterize the precipitants leading to both of these AD phenotypes. METHODS The multicenter, prospective, observational PREDICT study (NCT03056612) included 1,273 non-electively hospitalized patients with AD (No ACLF = 1,071; ACLF = 202). Medical history, clinical data and laboratory data were collected at enrolment and during 90-day follow-up, with particular attention given to the following characteristics of precipitants: induction of organ dysfunction or failure, systemic inflammation, chronology, intensity, and relationship to outcome. RESULTS Among various clinical events, 4 distinct events were precipitants consistently related to AD: proven bacterial infections, severe alcoholic hepatitis, gastrointestinal bleeding with shock and toxic encephalopathy. Among patients with precipitants in the AD-No ACLF cohort and the AD-ACLF cohort (38% and 71%, respectively), almost all (96% and 97%, respectively) showed proven bacterial infection and severe alcoholic hepatitis, either alone or in combination with other events. Survival was similar in patients with proven bacterial infections or severe alcoholic hepatitis in both AD phenotypes. The number of precipitants was associated with significantly increased 90-day mortality and was paralleled by increasing levels of surrogates for systemic inflammation. Importantly, adequate first-line antibiotic treatment of proven bacterial infections was associated with a lower ACLF development rate and lower 90-day mortality. CONCLUSIONS This study identified precipitants that are significantly associated with a distinct clinical course and prognosis in patients with AD. Specific preventive and therapeutic strategies targeting these events may improve outcomes in patients with decompensated cirrhosis. LAY SUMMARY Acute decompensation (AD) of cirrhosis is characterized by a rapid deterioration in patient health. Herein, we aimed to analyze the precipitating events that cause AD in patients with cirrhosis. Proven bacterial infections and severe alcoholic hepatitis, either alone or in combination, accounted for almost all (96-97%) cases of AD and acute-on-chronic liver failure. Whilst the type of precipitant was not associated with mortality, the number of precipitant(s) was. This study identified precipitants that are significantly associated with a distinct clinical course and prognosis of patients with AD. Specific preventive and therapeutic strategies targeting these events may improve patient outcomes.
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Affiliation(s)
- Jonel Trebicka
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; Department of Internal Medicine I, Goethe University Frankfurt, Frankfurt, Germany.
| | - Javier Fernandez
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; Hospital Clinic of Barcelona, University of Barcelona, CIBEReHD, IDIBAPS, Barcelona, Spain
| | - Maria Papp
- University of Debrecen, Faculty of Medicine, Institute of Medicine, Department of Gastroenterology, Debrecen, Hungary
| | | | - Wim Laleman
- Department of Gastroenterology and Hepatology, Section of Liver and Biliopancreatic disorders, University of Leuven, Leuven, Belgium
| | | | - Ilaria Giovo
- A.O.U. Città della Salute e della Scienza Torino, Torino, Italy
| | - Frank Erhard Uschner
- Department of Internal Medicine I, Goethe University Frankfurt, Frankfurt, Germany
| | - Christian Jansen
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Cesar Jimenez
- Liver Unit, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, CIBEREHD, Barcelona, Spain
| | | | | | - Agustin Albillos
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, CIBEREHD, Madrid, Spain
| | - Rafael Bañares
- Hospital General Universitario Gregorio Marañón. Facultad de Medicina (Universidad Complutense of Madrid), CIBERehd, Madrid, Spain
| | - Peter Jarcuska
- Pavol Jozef Safarik University in Kosice, Kosice, Slovakia
| | - Christian Steib
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU, Munich, Germany
| | | | - Juan Acevedo
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Pietro Gatti
- Internal Medicine PO Ostuni, ASL Brindisi, Italy
| | | | - Stefan Zeuzem
- Department of Internal Medicine I, Goethe University Frankfurt, Frankfurt, Germany
| | | | | | - Thomas Berg
- Division of Hepatology, Department of Medicine II, Leipzig University, Medical Center, Leipzig, Germany
| | - Tony Bruns
- Jena University Hospital, Jena, Germany; Aachen University Hospital, Aachen, Germany
| | - Karen Vagner Danielsen
- Gastrounit, Medical Section, Hvidovre Hospital and Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | | | | | | | - Heinz Zoller
- Medical University of Innsbruck, Innsbruck, Austria
| | | | - Cristina Solé
- Hospital Clinic of Barcelona, University of Barcelona, CIBEReHD, IDIBAPS, Barcelona, Spain
| | - Germán Soriano
- Hospital de la Santa Creu i Sant Pau and CIBERehd, Barcelona, Spain
| | - Andrea de Gottardi
- University Clinic of Visceral Surgery and Medicine-Inselspital, Bern and Ente Ospedaliero Cantonale, Universita della Svizzera Italiana, Lugano, Switzerland
| | | | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Universite Paris Saclay, INSERM Unit 1193, Villejuif, France
| | | | | | | | - Stephen Ryder
- NIHR Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, UK
| | - Pierre Nahon
- AP-HP, Hôpital Jean Verdier, Service d'Hépatologie, Bondy, France; Université Paris 13, Sorbonne Paris Cité, "Equipe labellisée Ligue Contre le Cancer", Saint-Denis, France; Inserm, UMR-1162, "Génomique fonctionnelle des tumeurs solides", Paris, France
| | | | | | - Claire Francoz
- APHP, Hôpital Beaujon, Service d'Hépatologie, Clichy, France; Inserm, Université de Paris, Centre de Recherche sur L´Inflammation, Paris, France
| | | | | | | | - Alex Amoros
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
| | - Marco Pavesi
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
| | - Cristina Sanchez
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
| | - Michael Praktiknjo
- Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany
| | - Anna Curto
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
| | - Carla Pitarch
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
| | | | - Esau Moreno
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
| | | | - Ferran Aguilar
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
| | - Joan Clària
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; Hospital Clinic of Barcelona, University of Barcelona, CIBEReHD, IDIBAPS, Barcelona, Spain
| | - Paola Ponzo
- A.O.U. Città della Salute e della Scienza Torino, Torino, Italy
| | - Zsuzsanna Vitalis
- University of Debrecen, Faculty of Medicine, Institute of Medicine, Department of Gastroenterology, Debrecen, Hungary
| | | | - Boglarka Balogh
- University of Debrecen, Faculty of Medicine, Institute of Medicine, Department of Gastroenterology, Debrecen, Hungary
| | - Alexander Gerbes
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU, Munich, Germany
| | - Victor Vargas
- Liver Unit, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, CIBEREHD, Barcelona, Spain
| | | | | | - Pere Ginès
- Hospital Clinic of Barcelona, University of Barcelona, CIBEReHD, IDIBAPS, Barcelona, Spain
| | - Richard Moreau
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; APHP, Hôpital Beaujon, Service d'Hépatologie, Clichy, France; Inserm, Université de Paris, Centre de Recherche sur L´Inflammation, Paris, France
| | - Paolo Angeli
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; University of Padova, Padova, Italy
| | - Rajiv Jalan
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; UCL Medical School,Royal Free Hospital, London, UK
| | - Vicente Arroyo
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
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Wong C, van den Broek W, Doody G, Fischer M, Leech M, De Ponti F, Gerbes A, Nishigori H, Lee YM, Frens M, Kasuya H, Bazzoli F, Hickel R, Lee HS, van Leeuwen J, Mitchell C, Kadomatsu K, Atherton J, Chan F. Continuing medical education during pandemic waves of COVID-19: Consensus from medical faculties in Asia, Australia and Europe. MedEdPublish (2016) 2021; 10:64. [PMID: 38486552 PMCID: PMC10939633 DOI: 10.15694/mep.2021.000064.1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/17/2024] Open
Abstract
This article was migrated. The article was marked as recommended. Medical faculties have the responsibility to train tomorrow's doctors and in a crisis face the challenge of delivering students into the workforce promptly and safely. Worldwide, medical faculties have faced unprecedented disruptions from viral outbreaks and pandemics including SARS, Ebola, H1N1 and COVID-19 which bring unique challenges. Currently there is worldwide disruption to medical faculties and medical education due to COVID-19. Despite close links with clinical medicine and the known risks of pandemics, many medical faculties have been caught off guard without pandemic planning in place, to deal with an exponential rise in infections and deaths, overwhelmed health services and widespread community risk of transmission. Assessing transmission risk of COVID-19 in teaching, clinical and community attachments and continuing medical education is paramount as medical faculties face subsequent pandemics waves. Consensus statements based on best available evidence and international expertise from medical faculties in Asia, Australia and Europe were developed to help guide the protection of staff and students, priorities on teaching activities and further educational development. Infection prevention, infection control, contact tracing and medical surveillance are detailed to minimise transmission and to enhance safety. Recommendations on teaching activities planning can enhance responsiveness of medical faculties to tackle subsequent waves of COVID-19 infection. A global approach and dialogue are encouraged.
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Wong F, Piano S, Singh V, Bartoletti M, Maiwall R, Alessandria C, Fernandez J, Soares EC, Kim DJ, Kim SE, Marino M, Vorobioff J, Barea RDCR, Merli M, Elkrief L, Vargas V, Krag A, Singh SP, Lesmana LA, Toledo C, Marciano S, Verhelst X, Intagliata N, Rabinowich L, Colombato L, Kim SG, Gerbes A, Durand F, Roblero JP, Bruns T, Yoon EL, Girala M, Pyrsopoulos NT, Kim TH, Yim SY, Juanola A, Gadano A, Angeli P. Clinical features and evolution of bacterial infection-related acute-on-chronic liver failure. J Hepatol 2021; 74:330-339. [PMID: 32781201 DOI: 10.1016/j.jhep.2020.07.046] [Citation(s) in RCA: 59] [Impact Index Per Article: 19.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/07/2020] [Revised: 07/20/2020] [Accepted: 07/29/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Bacterial infections can trigger the development of organ failure(s) and acute-on-chronic liver failure (ACLF). Geographic variations in bacteriology and clinical practice could lead to worldwide differences in ACLF epidemiology, phenotypes and associated outcomes. Herein, we aimed to evaluate regional differences in bacterial infection-related ACLF in patients with cirrhosis admitted to hospital. METHODS This post hoc analysis included 1,175 patients with decompensated cirrhosis (with bacterial infection on admission or nosocomial infection) from 6 geographic regions worldwide. Clinical, laboratory and microbiological data were collected from the diagnosis of infection. Patients were followed-up for organ failure(s) and ACLF development according to the EASL-CLIF criteria from enrolment to discharge/death. RESULTS A total of 333 patients (28%) had ACLF at diagnosis of infection, while 230 patients developed ACLF after diagnosis of infection, resulting in an overall rate of bacterial infection related-ACLF of 48%, with rates differing amongst different geographic regions (38% in Southern Europe vs. 75% in the Indian subcontinent). Bacterial infection related-ACLF more frequently developed in younger patients (55 ± 13 vs. 58 ± 14 years), males (73% vs. 62%), patients with alcohol-related cirrhosis (59% vs. 45%) and those with a higher baseline MELD score (25 ± 11 vs. 16 ± 5) (all p <0.001). Spontaneous bacterial peritonitis, pneumonia or infections caused by extensively drug resistant (XDR) bacteria were more frequently associated with ACLF development. More patients with ACLF had a positive quick sequential organ failure assessment score and septic shock, resulting in a lower infection resolution rate (all p <0.001). CONCLUSIONS Bacterial infections, especially with XDR organisms, are associated with the highest risk of ACLF development, accounting for almost half of cases globally. Geographic differences result in variable epidemiology and clinical outcomes. LAY SUMMARY Bacterial infections can trigger a sudden deterioration in an otherwise stable cirrhotic patient, a condition known as acute-on-chronic liver failure or ACLF. This study has found that the development of ACLF following bacterial infection occurs most commonly in the Indian subcontinent and less so in Southern Europe. The common infections that can trigger ACLF include infection of the abdominal fluid, known as spontaneous bacterial peritonitis, pneumonia and by bacteria that are resistant to multiple antibiotics. Patients who develop ACLF following a bacterial infection have high death rates and are frequently unable to clear the infection.
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Affiliation(s)
- Florence Wong
- Division of Gastroenterology, Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padova, Padova, Italy
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Michele Bartoletti
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Rakhi Maiwall
- Institute of Liver and Biliary Sciences, New Dehli, India
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS); Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED); European Foundation of Chronic Liver Failure (EF-Clif), Barcelona
| | - Elza Cotrim Soares
- Gastroenterology Division, Medicine Department, Faculty of Medical Sciences, University of Campinas (UNICAMP). Campinas, São Paulo, Brazil
| | - Dong Joon Kim
- Institute for Liver and Digestive Diseases, Hallym University College of Medicine, Chuncheon, South Korea
| | - Sung Eun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Sacred Heart Hospital, College of Medicine, Hallym University, Anyang city, Republic of Korea
| | - Monica Marino
- Liver Unit, Hospital Dr. Carlos B. Udaondo, Buenos Aires, Argentina
| | | | | | - Manuela Merli
- Gastroenterology and Hepatology Unit, Department of Translational and Precision Medicine, Sapienza Università di Roma, Rome, Italy
| | - Laure Elkrief
- Service de Transplantation, Service d'Hépato-gastroentérologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Victor Vargas
- Liver Unit, Department of Internal Medicine, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | | | | | - Claudio Toledo
- Gastroenterology Unit, Hospital Valdivia, Universidad Austral de Chile, Valdivia, Chile
| | - Sebastian Marciano
- Liver Unit and Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Nicolas Intagliata
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia, USA
| | - Liane Rabinowich
- Liver Unit, Department of Gastroenterology, Tel-Aviv Medical Center and Tel-Aviv University, Tel-Aviv, Israel
| | - Luis Colombato
- Gastroenterology Department, Buenos Aires British Hospital, Argentine Catholic University (UCA), Buenos Aires, Argentina
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Alexander Gerbes
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU Munich, Germany
| | - Francois Durand
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, University Paris Diderot, Paris, France
| | - Juan Pablo Roblero
- Departamento de Medicina, Universidad de Chile Campus Centro, Hospital Clínico San Borja Arriarán, Santiago, Chile
| | - Tony Bruns
- Department of Internal Medicine IV, Jena University Hospital, Jena, Germany; Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Eileen Laurel Yoon
- Department of Internal Medicine, Sanggye Paik Hospital, Inje University, Seoul, Republic of Korea
| | - Marcos Girala
- Departamento de Gastroenterología y Endoscopia Digestiva, Hospital de Clínicas, Universidad Nacional de Asunción, Asunción, Paraguay
| | - Nikolaos T Pyrsopoulos
- Division of Gastroenterology and Hepatology, Rutgers- New Jersey Medical School, University Hospital, Newark, NJ, USA
| | - Tae Hun Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Sun Young Yim
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Korea University Hospital, Seoul, Republic of Korea
| | - Adria Juanola
- Liver ICU, Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS); Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED)
| | - Adrian Gadano
- Gastroenterology Unit, Hospital Valdivia, Universidad Austral de Chile, Valdivia, Chile
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine - DIMED, University of Padova, Padova, Italy; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona.
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10
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Trieb M, Rainer F, Stadlbauer V, Douschan P, Horvath A, Binder L, Trakaki A, Knuplez E, Scharnagl H, Stojakovic T, Heinemann Á, Mandorfer M, Paternostro R, Reiberger T, Pitarch C, Amorós A, Gerbes A, Caraceni P, Alessandria C, Moreau R, Clària J, Marsche G, Stauber RE. HDL-related biomarkers are robust predictors of survival in patients with chronic liver failure. J Hepatol 2020; 73:113-120. [PMID: 32061870 DOI: 10.1016/j.jhep.2020.01.026] [Citation(s) in RCA: 53] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2019] [Revised: 01/21/2020] [Accepted: 01/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS High-density lipoprotein cholesterol (HDL-C) levels are reduced in patients with chronic liver disease and inversely correlate with disease severity. During acute conditions such as sepsis, HDL-C levels decrease rapidly and HDL particles undergo profound changes in their composition and function. We aimed to determine whether indices of HDL quantity and quality associate with progression and survival in patients with advanced liver disease. METHODS HDL-related biomarkers were studied in 508 patients with compensated or decompensated cirrhosis (including acute-on-chronic liver failure [ACLF]) and 40 age- and gender-matched controls. Specifically, we studied levels of HDL-C, its subclasses HDL2-C and HDL3-C, and apolipoprotein A1 (apoA-I), as well as HDL cholesterol efflux capacity as a metric of HDL functionality. RESULTS Baseline levels of HDL-C and apoA-I were significantly lower in patients with stable cirrhosis compared to controls and were further decreased in patients with acute decompensation (AD) and ACLF. In stable cirrhosis (n = 228), both HDL-C and apoA-I predicted the development of liver-related complications independently of model for end-stage liver disease (MELD) score. In patients with AD, with or without ACLF (n = 280), both HDL-C and apoA-I were MELD-independent predictors of 90-day mortality. On ROC analysis, both HDL-C and apoA-I had high diagnostic accuracy for 90-day mortality in patients with AD (AUROCs of 0.79 and 0.80, respectively, similar to that of MELD 0.81). On Kaplan-Meier analysis, HDL-C <17 mg/dl and apoA-I <50 mg/dl indicated poor short-term survival. The prognostic accuracy of HDL-C was validated in a large external validation cohort of 985 patients with portal hypertension due to advanced chronic liver disease (AUROCs HDL-C: 0.81 vs. MELD: 0.77). CONCLUSION HDL-related biomarkers are robust predictors of disease progression and survival in chronic liver failure. LAY SUMMARY People who suffer from cirrhosis (scarring of the liver) have low levels of cholesterol carried by high-density lipoproteins (HDL-C). These alterations are connected to inflammation, which is a problem in severe liver disease. Herein, we show that reduced levels of HDL-C and apolipoprotein A-I (apoA-I, the main protein carried by HDL) are closely linked to the severity of liver failure, its complications and survival. Both HDL-C and apoA-I can be easily measured in clinical laboratories and are as good as currently used prognostic scores calculated from several laboratory values by complex formulas.
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Affiliation(s)
- Markus Trieb
- Division of Pharmacology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria; BioTechMed-Graz, Graz, Austria
| | - Florian Rainer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Vanessa Stadlbauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Philipp Douschan
- Division of Pulmonology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Angela Horvath
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria; Center for Biomarker Research in Medicine (CBmed), Graz, Austria
| | - Lukas Binder
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Athina Trakaki
- Division of Pharmacology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Eva Knuplez
- Division of Pharmacology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Hubert Scharnagl
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Tatjana Stojakovic
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, University Hospital Graz, Graz, Austria
| | - Ákos Heinemann
- Division of Pharmacology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Carla Pitarch
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain
| | - Alex Amorós
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain
| | - Alexander Gerbes
- Department of Medicine II, University Hospital, LMU Munich, Munich, Germany
| | - Paolo Caraceni
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain; Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carlo Alessandria
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain; Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain; Institut national de la Santé et de la Recherche Médicale, Université de Paris, Centre de Recherche sur l'Inflammation, Paris et Service d'hépatologie, Hôpital Beaujon, APHP, Clichy, France
| | - Joan Clària
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain; Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Gunther Marsche
- Division of Pharmacology, Otto Loewi Research Center, Medical University of Graz, Graz, Austria; BioTechMed-Graz, Graz, Austria.
| | - Rudolf E Stauber
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria.
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Moreau R, Clària J, Aguilar F, Fenaille F, Lozano JJ, Junot C, Colsch B, Caraceni P, Trebicka J, Pavesi M, Alessandria C, Nevens F, Saliba F, Welzel TM, Albillos A, Gustot T, Fernández J, Moreno C, Baldassarre M, Zaccherini G, Piano S, Montagnese S, Vargas V, Genescà J, Solà E, Bernal W, Butin N, Hautbergue T, Cholet S, Castelli F, Jansen C, Steib C, Campion D, Mookerjee R, Rodríguez-Gandía M, Soriano G, Durand F, Benten D, Bañares R, Stauber RE, Gronbaek H, Coenraad MJ, Ginès P, Gerbes A, Jalan R, Bernardi M, Arroyo V, Angeli P. Correction to 'Blood metabolomics uncovers inflammation-associated mitochondrial dysfunction as a potential mechanism underlying ACLF' [J Hepatol 2020 (72) 688-701]. J Hepatol 2020; 72:1218-1220. [PMID: 32192825 DOI: 10.1016/j.jhep.2020.03.002] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/04/2022]
Affiliation(s)
- Richard Moreau
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Inserm, U1149, Centre de Recherche sur l'Inflammation (CRI), UMRS1149, Université de Paris, Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France.
| | - Joan Clària
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Hospital Clínic-IDIBAPS, Universitat de Barcelona, Barcelona, Spain; CIBERehd, Barcelona, Spain
| | - Ferran Aguilar
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - François Fenaille
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | | | - Christophe Junot
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Benoit Colsch
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Jonel Trebicka
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; J.W. Goethe University Hospital, Frankfurt, Germany
| | - Marco Pavesi
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino, Italy
| | | | - Faouzi Saliba
- Hôpital Paul Brousse, Université Paris-Sud, Villejuif, France
| | | | | | - Thierry Gustot
- CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Javier Fernández
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Hospital Clínic-IDIBAPS, Universitat de Barcelona, Barcelona, Spain; CIBERehd, Barcelona, Spain
| | - Christophe Moreno
- CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Maurizio Baldassarre
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Dept. of Medicine, DIMED, University of Padova, Italy
| | - Sara Montagnese
- Unit of Internal Medicine and Hepatology, Dept. of Medicine, DIMED, University of Padova, Italy
| | - Victor Vargas
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Genescà
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elsa Solà
- Hospital Clínic-IDIBAPS, Universitat de Barcelona, Barcelona, Spain; CIBERehd, Barcelona, Spain
| | - William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Division of Inflammation Biology, King's College London, London, UK
| | - Noémie Butin
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Thaïs Hautbergue
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Sophie Cholet
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Florence Castelli
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | | | - Christian Steib
- Department of Medicine II, Liver Center Munich, University Hospital LMU Munich, Munich, Germany
| | - Daniela Campion
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino, Italy
| | - Raj Mookerjee
- Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London, UK
| | | | - German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - François Durand
- Inserm, U1149, Centre de Recherche sur l'Inflammation (CRI), UMRS1149, Université de Paris, Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | | | - Rafael Bañares
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Henning Gronbaek
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Pere Ginès
- Hospital Clínic-IDIBAPS, Universitat de Barcelona, Barcelona, Spain; CIBERehd, Barcelona, Spain
| | - Alexander Gerbes
- Department of Medicine II, Liver Center Munich, University Hospital LMU Munich, Munich, Germany
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London, UK
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vicente Arroyo
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - Paolo Angeli
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Unit of Internal Medicine and Hepatology, Dept. of Medicine, DIMED, University of Padova, Italy
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Moreau R, Clària J, Aguilar F, Fenaille F, Lozano JJ, Junot C, Colsch B, Caraceni P, Trebicka J, Pavesi M, Alessandria C, Nevens F, Saliba F, Welzel TM, Albillos A, Gustot T, Fernández J, Moreno C, Baldassarre M, Zaccherini G, Piano S, Montagnese S, Vargas V, Genescà J, Solà E, Bernal W, Butin N, Hautbergue T, Cholet S, Castelli F, Jansen C, Steib C, Campion D, Mookerjee R, Rodríguez-Gandía M, Soriano G, Durand F, Benten D, Bañares R, Stauber RE, Gronbaek H, Coenraad MJ, Ginès P, Gerbes A, Jalan R, Bernardi M, Arroyo V, Angeli P. Blood metabolomics uncovers inflammation-associated mitochondrial dysfunction as a potential mechanism underlying ACLF. J Hepatol 2020; 72:688-701. [PMID: 31778751 DOI: 10.1016/j.jhep.2019.11.009] [Citation(s) in RCA: 194] [Impact Index Per Article: 48.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/10/2019] [Revised: 10/29/2019] [Accepted: 11/11/2019] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF), which develops in patients with cirrhosis, is characterized by intense systemic inflammation and organ failure(s). Because systemic inflammation is energetically expensive, its metabolic costs may result in organ dysfunction/failure. Therefore, we aimed to analyze the blood metabolome in patients with cirrhosis, with and without ACLF. METHODS We performed untargeted metabolomics using liquid chromatography coupled to high-resolution mass spectrometry in serum from 650 patients with AD (acute decompensation of cirrhosis, without ACLF), 181 with ACLF, 43 with compensated cirrhosis, and 29 healthy individuals. RESULTS Of the 137 annotated metabolites identified, 100 were increased in patients with ACLF of any grade, relative to those with AD, and 38 comprised a distinctive blood metabolite fingerprint for ACLF. Among patients with ACLF, the intensity of the fingerprint increased across ACLF grades, and was similar in patients with kidney failure and in those without, indicating that the fingerprint reflected not only decreased kidney excretion but also altered cell metabolism. The higher the ACLF-associated fingerprint intensity, the higher the plasma levels of inflammatory markers, tumor necrosis factor α, soluble CD206, and soluble CD163. ACLF was characterized by intense proteolysis and lipolysis; amino acid catabolism; extra-mitochondrial glucose metabolism through glycolysis, pentose phosphate, and D-glucuronate pathways; depressed mitochondrial ATP-producing fatty acid β-oxidation; and extra-mitochondrial amino acid metabolism giving rise to metabotoxins. CONCLUSIONS In ACLF, intense systemic inflammation is associated with blood metabolite accumulation and profound alterations in major metabolic pathways, in particular inhibition of mitochondrial energy production, which may contribute to the development of organ failures. LAY SUMMARY Acute-on-chronic liver failure (ACLF), which develops in patients with cirrhosis, is characterized by intense systemic inflammation and organ failure(s). Because systemic inflammation is energetically expensive, its metabolic costs may result in organ dysfunction/failure. We identified a 38-metabolite blood fingerprint specific for ACLF that revealed mitochondrial dysfunction in peripheral organs. This may contribute to organ failures.
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Affiliation(s)
- Richard Moreau
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Inserm, U1149, Centre de Recherche sur l'Inflammation (CRI) UMRS1149, Université de Paris, Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France.
| | - Joan Clària
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Hospital Clínic-IDIBAPS, Universitat de Barcelona, Barcelona, Spain; CIBERehd, Barcelona, Spain
| | - Ferran Aguilar
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - François Fenaille
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | | | - Christophe Junot
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Benoit Colsch
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Jonel Trebicka
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; J.W. Goethe University Hospital, Frankfurt, Germany
| | - Marco Pavesi
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino, Italy
| | | | - Faouzi Saliba
- Hôpital Paul Brousse, Université Paris-Sud, Villejuif, France
| | | | - Agustin Albillos
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, CIBEREHD, Madrid, Spain
| | - Thierry Gustot
- CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Javier Fernández
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Hospital Clínic-IDIBAPS, Universitat de Barcelona, Barcelona, Spain; CIBERehd, Barcelona, Spain
| | - Christophe Moreno
- CUB Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Maurizio Baldassarre
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Dept. of Medicine, DIMED, University of Padova, Italy
| | - Sara Montagnese
- Unit of Internal Medicine and Hepatology, Dept. of Medicine, DIMED, University of Padova, Italy
| | - Victor Vargas
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Joan Genescà
- Liver Unit, Hospital Universitari Vall d'Hebron, Vall d'Hebron Institute of Research (VHIR), Universitat Autònoma de Barcelona, Barcelona, Spain
| | - Elsa Solà
- Hospital Clínic-IDIBAPS, Universitat de Barcelona, Barcelona, Spain; CIBERehd, Barcelona, Spain
| | - William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Division of Inflammation Biology, King's College London, London, UK
| | - Noémie Butin
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Thaïs Hautbergue
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Sophie Cholet
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | - Florence Castelli
- Service de Pharmacologie et Immuno-Analyse (SPI), Laboratoire d'Etude du Métabolisme des Médicaments, CEA, INRA, Université Paris Saclay, MetaboHUB, F-91191 Gif-sur-Yvette, France
| | | | - Christian Steib
- Department of Medicine II, Liver Center Munich, University Hospital LMU Munich, Munich, Germany
| | - Daniela Campion
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino, Italy
| | - Raj Mookerjee
- Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London, UK
| | - Miguel Rodríguez-Gandía
- Department of Gastroenterology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, CIBEREHD, Madrid, Spain
| | - German Soriano
- Department of Gastroenterology, Hospital de la Santa Creu i Sant Pau, Universitat Autònoma de Barcelona, Barcelona, Spain
| | - François Durand
- Inserm, U1149, Centre de Recherche sur l'Inflammation (CRI) UMRS1149, Université de Paris, Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | | | - Rafael Bañares
- Digestive Diseases Department, Hospital General Universitario Gregorio Marañón; Instituto de Investigación Sanitaria Gregorio Marañón; Facultad de Medicina, Universidad Complutense, Madrid; and CIBERehd
| | | | - Henning Gronbaek
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Pere Ginès
- Hospital Clínic-IDIBAPS, Universitat de Barcelona, Barcelona, Spain; CIBERehd, Barcelona, Spain
| | - Alexander Gerbes
- Department of Medicine II, Liver Center Munich, University Hospital LMU Munich, Munich, Germany
| | - Rajiv Jalan
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London, UK
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vicente Arroyo
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - Paolo Angeli
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Unit of Internal Medicine and Hepatology, Dept. of Medicine, DIMED, University of Padova, Italy
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Li H, Wieser A, Zhang J, Liss I, Markwardt D, Hornung R, Neumann-Cip AC, Mayerle J, Gerbes A, Steib CJ. Patients with cirrhosis and SBP: Increase in multidrug-resistant organisms and complications. Eur J Clin Invest 2020; 50:e13198. [PMID: 31886517 DOI: 10.1111/eci.13198] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/24/2018] [Revised: 11/07/2019] [Accepted: 12/29/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a serious complication in patients with liver cirrhosis. In recent years, it has been postulated that the rate of multidrug-resistant organisms (MDROs) is increasing, especially in nosocomial SBP patients. Aim of the present work was to investigate this hypothesis and its possible clinical consequences. MATERIALS AND METHODS One hundred and three culture-positive patients between 2007 and 2014 were compared with 81 patients between 2015 and 2017, to study the change of microbiological profiles and their clinical consequences. The cirrhosis patients with bacterascites requiring treatment were included as well. RESULTS The most prevalent Gram-negative bacteria isolated from ascites were Enterobacterales (31.6%) and in Gram-positive pathogens Staphylococci (22.8%). There was a significant increase in MDROs (22.3% ICU 40.7%, P = .048), accompanied by an increased incidence of sepsis (from 21.4% to 37.0%, P = .021), hepatorenal syndrome (from 40.8% to 58.0%, P = .007) and the need of catecholamine therapy (from 21.4% to 38.8%, P = .036). Nosocomial origin correlated with higher MDRO proportion, more complications and lower antimicrobial susceptibility rates in 12 commonly used antibiotics. MDROs were confirmed as an isolated predictor for inpatient mortality and complications in multivariable logistic regression. CONCLUSIONS The feeling in clinical practice that MDROs have increased in the last 11 years could be confirmed in our study in Munich, Germany. Nosocomial SBP correlated with significantly higher MDRO rates (nearly 50%) and complication rates. In our opinion, an antibiotic combination with comprehensive effect should be taken into account in nosocomial SBP patients in this region.
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Affiliation(s)
- Hanwei Li
- Department of Medicine II, Liver Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - Andreas Wieser
- Medical Microbiology and Hospital Epidemiology, Max von Pettenkofer Institute, Faculty of Medicine, LMU Munich, Munich, Germany.,Division of Infectious Diseases and Tropical Medicine, University Hospital, LMU Munich, Munich, Germany.,German Centre for Infection Research (DZIF), Munich, Germany
| | - Jiang Zhang
- Department of Medicine II, Liver Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - Ingrid Liss
- Department of Medicine II, Liver Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - Daniel Markwardt
- Department of Medicine II, Liver Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - Roman Hornung
- Institute for Medical Information Processing, Biometry and Epidemiology (IBE), LMU Munich, Munich, Germany
| | - Anna C Neumann-Cip
- Medical Microbiology and Hospital Epidemiology, Max von Pettenkofer Institute, Faculty of Medicine, LMU Munich, Munich, Germany.,German Centre for Infection Research (DZIF), Munich, Germany
| | - Julia Mayerle
- Department of Medicine II, Liver Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - Alexander Gerbes
- Department of Medicine II, Liver Center Munich, University Hospital, LMU Munich, Munich, Germany
| | - Christian J Steib
- Department of Medicine II, Liver Center Munich, University Hospital, LMU Munich, Munich, Germany
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14
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Rust C, Gerbes A. [How to deal with increased liver markers]. MMW Fortschr Med 2019; 159:68-70. [PMID: 29124577 DOI: 10.1007/s15006-017-0283-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Affiliation(s)
- Christian Rust
- Innere Medizin I - Gastroenterologie, Krankenhaus Barmherzige Brüder, Romanstraße 93, D-80639, München, Deutschland.
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15
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Fernández J, Clària J, Amorós A, Aguilar F, Castro M, Casulleras M, Acevedo J, Duran-Güell M, Nuñez L, Costa M, Torres M, Horrillo R, Ruiz-Del-Árbol L, Villanueva C, Prado V, Arteaga M, Trebicka J, Angeli P, Merli M, Alessandria C, Aagaard NK, Soriano G, Durand F, Gerbes A, Gustot T, Welzel TM, Salerno F, Bañares R, Vargas V, Albillos A, Silva A, Morales-Ruiz M, Carlos García-Pagán J, Pavesi M, Jalan R, Bernardi M, Moreau R, Páez A, Arroyo V. Effects of Albumin Treatment on Systemic and Portal Hemodynamics and Systemic Inflammation in Patients With Decompensated Cirrhosis. Gastroenterology 2019; 157:149-162. [PMID: 30905652 DOI: 10.1053/j.gastro.2019.03.021] [Citation(s) in RCA: 146] [Impact Index Per Article: 29.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/19/2018] [Revised: 02/25/2019] [Accepted: 03/14/2019] [Indexed: 01/29/2023]
Abstract
BACKGROUND & AIMS We investigated the effect of albumin treatment (20% solution) on hypoalbuminemia, cardiocirculatory dysfunction, portal hypertension, and systemic inflammation in patients with decompensated cirrhosis with and without bacterial infections. METHODS We performed a prospective study to assess the effects of long-term (12 weeks) treatment with low doses (1 g/kg body weight every 2 weeks) and high doses (1.5 g/kg every week) of albumin on serum albumin, plasma renin, cardiocirculatory function, portal pressure, and plasma levels of cytokines, collecting data from 18 patients without bacterial infections (the Pilot-PRECIOSA study). We also assessed the effect of short-term (1 week) treatment with antibiotics alone vs the combination of albumin plus antibiotics (1.5 g/kg on day 1 and 1 g/kg on day 3) on plasma levels of cytokines in biobanked samples from 78 patients with bacterial infections included in a randomized controlled trial (INFECIR-2 study). RESULTS Circulatory dysfunction and systemic inflammation were extremely unstable in many patients included in the Pilot-PRECIOSA study; these patients had intense and reversible peaks in plasma levels of renin and interleukin 6. Long-term high-dose albumin, but not low-dose albumin, was associated with normalization of serum level of albumin, improved stability of the circulation and left ventricular function, and reduced plasma levels of cytokines (interleukin 6, granulocyte colony-stimulating factor, interleukin 1 receptor antagonist, and vascular endothelial growth factor) without significant changes in portal pressure. The immune-modulatory effects of albumin observed in the Pilot-PRECIOSA study were confirmed in the INFECIR-2 study. In this study, patients given albumin had significant reductions in plasma levels of cytokines. CONCLUSIONS In an analysis of data from 2 trials (Pilot-PRECIOSA study and INFECIR-2 study), we found that albumin treatment reduced systemic inflammation and cardiocirculatory dysfunction in patients with decompensated cirrhosis. These effects might be responsible for the beneficial effects of albumin therapy on outcomes of patients with decompensated cirrhosis. ClinicalTrials.gov, Numbers: NCT00968695 and NCT03451292.
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Affiliation(s)
- Javier Fernández
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain.
| | - Joan Clària
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Alex Amorós
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - Ferrán Aguilar
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - Miriam Castro
- Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | | | - Juan Acevedo
- South West Liver Unit, Derriford Hospital, Plymouth, United Kingdom
| | | | - Laura Nuñez
- Bioscience Research Group, Grifols, Barcelona, Spain
| | | | - Mireia Torres
- Bioscience Research Group, Grifols, Barcelona, Spain
| | | | - Luis Ruiz-Del-Árbol
- Department of Gastroenterology, Hospital Ramón y Cajal and CIBERehd, Madrid, Spain
| | - Cándido Villanueva
- Department of Gastroenterology, Hospital de Sant Pau and CIBERehd, Barcelona, Spain
| | | | | | - Jonel Trebicka
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Department of Internal Medicine, University Hospital of Bonn, Bonn, Germany
| | - Paolo Angeli
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Unit of Internal Medicine and Hepatology, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Manuela Merli
- Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino, Italy
| | - Niels Kristian Aagaard
- Department of Hepatology and Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - German Soriano
- Department of Gastroenterology and Hepatology, Hospital of Santa Creu i Sant Pau and CIBERehd, Barcelona, Spain
| | - François Durand
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
| | - Alexander Gerbes
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU Munich, Munich, Germany
| | - Thierry Gustot
- Liver Transplant Unit, Erasme Hospital (ULB), Brussels, Belgium
| | - Tania M Welzel
- Medical Department I, Goethe University, Frankfurt, Germany
| | - Francesco Salerno
- Department of Internal Medicine, Policlinico IRCCS San Donato, Milano, Italy
| | - Rafael Bañares
- Department of Gastroenterology, Hospital Gregorio Marañon, and CIBERehd, Madrid, Spain
| | - Victor Vargas
- Department of Internal Medicine, Hospital Vall d'Hebron and CIBERehd, Barcelona, Spain
| | - Agustin Albillos
- Department of Gastroenterology, Hospital Ramón y Cajal and CIBERehd, Madrid, Spain
| | - Aníbal Silva
- Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | | | | | - Marco Pavesi
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London, United Kingdom
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Richard Moreau
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain; Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France; Inserm, Université Paris Diderot-Paris 7, Centre de Recherche sur l'Inflammation, Paris, France
| | - Antonio Páez
- Bioscience Research Group, Grifols, Barcelona, Spain
| | - Vicente Arroyo
- EF Clif, EASL-CLIF Consortium and Grifols Chair, Barcelona, Spain
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16
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Hernaez R, Kramer JR, Liu Y, Tansel A, Natarajan Y, Hussain KB, Ginès P, Solà E, Moreau R, Gerbes A, El-Serag HB, Kanwal F. Prevalence and short-term mortality of acute-on-chronic liver failure: A national cohort study from the USA. J Hepatol 2019; 70:639-647. [PMID: 30590100 DOI: 10.1016/j.jhep.2018.12.018] [Citation(s) in RCA: 84] [Impact Index Per Article: 16.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2018] [Revised: 11/21/2018] [Accepted: 12/11/2018] [Indexed: 12/30/2022]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is characterised by the presence of organ failure in patients with decompensated cirrhosis and is associated with high short-term mortality. However, there are limited data on the prevalence and short-term outcomes of ACLF in patients with cirrhosis seen in the US. We aimed to study the prevalence and risk factors associated with the development and short term mortality in a large cohort of patients in the US. METHODS Using the US Department of Veterans Affairs (VA) Corporate Data Warehouse, we identified patients with ACLF during hospitalisation for decompensated cirrhosis at any of the 127 VA hospitals between January 1, 2004, and December 31, 2014. We examined the prevalence of ACLF and variables associated with 28- and 90-day mortality in ACLF, and trends in prevalence and survival over time. RESULTS Of 72,316 patients hospitalised for decompensated cirrhosis, 19,082 (26.4%) patients met the criteria of ACLF on admission. Of these, 12.8% had 1, 10.1% had 2, and 3.5% had 3 or more organ failures. Overall, 25.5% and 40.0% of ACLF patients died within 28 days and 90 days of admission, respectively. Older age, White race, liver cancer, higher model for end-stage liver disease sodium corrected score, and non-liver transplant centre were associated with increased risk of death in ACLF. Over the study period, the prevalence of ACLF decreased, and all grades but ACLF-3 had improvement in survival. CONCLUSIONS In a US cohort of hospitalised patients with decompensated cirrhosis, ACLF was common and associated with high short-term mortality. Over a decade, ACLF prevalence decreased but survival improvement of ACLF-3 was not seen. Early recognition and aggressive management including timely referral to transplant centres may lead to improved outcomes in ACLF. LAY SUMMARY Acute-on-chronic liver failure (ACLF) is a condition marked by multiple organ failures in patients with cirrhosis and associated with a high risk of death. In this study of US patients hospitalised with cirrhosis, 1 in 4 patients developed ACLF. In total, 25% of patients with ACLF died within 1 month and 40% died within 3 months. Thus, early recognition of ACLF is important for the initiation of aggressive management, which is required to save these patients' lives.
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Affiliation(s)
- Ruben Hernaez
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
| | - Jennifer R Kramer
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Yan Liu
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Aylin Tansel
- Section of Gastroenterology, Department of Medicine, Medical University of South Carolina, Charleston, SC, USA
| | - Yamini Natarajan
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Khozema B Hussain
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Pere Ginès
- Liver Unit, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centros de Investigación Biomédica en Red, enfermedades Hepaticas y Digestivas (CIBEReHD), Barcelona, Spain; European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain
| | - Elsa Solà
- Liver Unit, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain; Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centros de Investigación Biomédica en Red, enfermedades Hepaticas y Digestivas (CIBEReHD), Barcelona, Spain; European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain; Inserm, U1149, Centre de Recerche sur l'inflammation (CRI), Paris, France; Faculté de Médicine, Université Paris Diderot, Paris, France; Départment Hospitalo-Universitaire (DHU) UNITY, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France
| | - Alexander Gerbes
- Liver Centre Munich, Department of Medicine II, University Hospital, LMU Munich, Germany
| | - Hashem B El-Serag
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Fasiha Kanwal
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, USA; Center for Innovations in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
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Piano S, Singh V, Caraceni P, Maiwall R, Alessandria C, Fernandez J, Soares EC, Kim DJ, Kim SE, Marino M, Vorobioff J, Barea RDCR, Merli M, Elkrief L, Vargas V, Krag A, Singh SP, Lesmana LA, Toledo C, Marciano S, Verhelst X, Wong F, Intagliata N, Rabinowich L, Colombato L, Kim SG, Gerbes A, Durand F, Roblero JP, Bhamidimarri KR, Boyer TD, Maevskaya M, Fassio E, Kim HS, Hwang JS, Gines P, Gadano A, Sarin SK, Angeli P, Brodersen C, Bruns T, de Man RA, Fialla AD, Gambino C, Gautam V, Girala M, Juanola A, Kim JH, Kim TH, Kumar P, Lattanzi B, Lee TH, Rinaldi Lesmana CA, Moreau R, Nath P, Navarro G, Park JW, Pinero G, Pyrsopoulos NT, Restellini S, Romero G, Sacco M, Sevá-Pereira T, Simón-Talero M, Song DS, Suk KT, Van Vlierberghe H, Yim SY, Yoon EL, Zaccherini G. Epidemiology and Effects of Bacterial Infections in Patients With Cirrhosis Worldwide. Gastroenterology 2019; 156:1368-1380.e10. [PMID: 30552895 DOI: 10.1053/j.gastro.2018.12.005] [Citation(s) in RCA: 249] [Impact Index Per Article: 49.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2018] [Revised: 11/30/2018] [Accepted: 12/07/2018] [Indexed: 02/08/2023]
Abstract
BACKGROUND & AIMS Bacterial infections are common and life-threatening in patients with cirrhosis. Little is known about the epidemiology of bacterial infections in different regions. We performed a multicenter prospective intercontinental study to assess the prevalence and outcomes of bacterial and fungal infections in patients with cirrhosis. METHODS We collected data from 1302 hospitalized patients with cirrhosis and bacterial or fungal infections at 46 centers (15 in Asia, 15 in Europe, 11 in South America, and 5 in North America) from October 2015 through September 2016. We obtained demographic, clinical, microbiology, and treatment data at time of diagnosis of infection and during hospitalization. Patients were followed until death, liver transplantation, or discharge. RESULTS The global prevalence of multidrug-resistant (MDR) bacteria was 34% (95% confidence interval 31%-37%). The prevalence of MDR bacteria differed significantly among geographic areas, with the greatest prevalence in Asia. Independent risk factors for infection with MDR bacteria were infection in Asia (particularly in India), use of antibiotics in the 3 months before hospitalization, prior health care exposure, and site of infection. Infections caused by MDR bacteria were associated with a lower rate of resolution of infection, a higher incidence of shock and new organ failures, and higher in-hospital mortality than those caused by non-MDR bacteria. Administration of adequate empirical antibiotic treatment was independently associated with improved in-hospital and 28-day survival. CONCLUSIONS In a worldwide study of hospitalized patients, we found a high prevalence of infection with MDR bacteria in patients with cirrhosis. Differences in the prevalence of MDR bacterial infections in different global regions indicate the need for different empirical antibiotic strategies in different continents and countries. While we await new antibiotics, effort should be made to decrease the spread of MDR bacteria in patients with cirrhosis.
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Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy
| | - Virendra Singh
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Rakhi Maiwall
- Institute of Liver and Biliary Sciences, New Delhi, India
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Turin, Turin, Italy
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Catalonia, Spain; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Catalonia, Spain
| | - Elza Cotrim Soares
- Gastroenterology Division, Medicine Department, Faculty of Medical Sciences, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Sung Eun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Hallym Sacred Heart Hospital, College of Medicine, Hallym University, Anyang City, Republic of Korea
| | - Monica Marino
- Liver Unit, Hospital Dr. Carlos B. Udaondo, Buenos Aires, Argentina
| | | | | | - Manuela Merli
- Gastroenterology and Hepatology Unit, Department of Clinical Medicine, Sapienza University of Rome, Rome, Italy
| | - Laure Elkrief
- Service de Transplantation, Service d'Hépato-gastroentérologie, Hôpitaux Universitaires de Genève, Geneva, Switzerland
| | - Victor Vargas
- Liver Unit, Department of Internal Medicine, Hospital Vall d'Hebron, Universitat Autònoma de Barcelona, CIBERehd, Barcelona, Spain
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | | | | | - Claudio Toledo
- Gastroenterology Unit, Hospital Valdivia, Universidad Austral de Chile, Valdivia, Chile
| | - Sebastian Marciano
- Liver Unit and Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | - Xavier Verhelst
- Department of Gastroenterology and Hepatology, Ghent University Hospital, Ghent, Belgium
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Ontario, Canada
| | - Nicolas Intagliata
- Division of Gastroenterology and Hepatology, University of Virginia, Charlottesville, Virginia
| | - Liane Rabinowich
- Liver Unit, Department of Gastroenterology, Tel-Aviv Medical Center and Tel-Aviv University, Tel-Aviv, Israel
| | - Luis Colombato
- Gastroenterology Department, Buenos Aires British Hospital, Argentine Catholic University, Buenos Aires, Argentina
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Alexander Gerbes
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU Munich, Germany
| | - Francois Durand
- Hepatology & Liver Intensive Care, Hospital Beaujon, Clichy, University Paris Diderot, Paris, France
| | - Juan Pablo Roblero
- Departamento de Medicina, Universidad de Chile Campus Centro, Hospital Clínico San Borja Arriarán, Santiago, Chile
| | | | - Thomas D Boyer
- Department of Medicine, University of Arizona, Tucson, Arizona
| | | | - Eduardo Fassio
- Liver Unit, Hospital Nacional Prof. Alejandro Posadas, El Palomar, Buenos Aires, Argentina
| | - Hyoung Su Kim
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Jae Seok Hwang
- Department of Internal Medicine, Keimyung University School of Medicine, Daegu, Republic of Korea
| | - Pere Gines
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Catalonia, Spain; Institut d'Investigacions Biomèdiques August-Pi-Sunyer, Barcelona, Catalonia, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Catalonia, Spain
| | - Adrian Gadano
- Liver Unit and Department of Research, Hospital Italiano de Buenos Aires, Buenos Aires, Argentina
| | | | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy.
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18
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Clària J, Moreau R, Fenaille F, Amorós A, Junot C, Gronbaek H, Coenraad MJ, Pruvost A, Ghettas A, Chu-Van E, López-Vicario C, Oettl K, Caraceni P, Alessandria C, Trebicka J, Pavesi M, Deulofeu C, Albillos A, Gustot T, Welzel TM, Fernández J, Stauber RE, Saliba F, Butin N, Colsch B, Moreno C, Durand F, Nevens F, Bañares R, Benten D, Ginès P, Gerbes A, Jalan R, Angeli P, Bernardi M, Arroyo V. Orchestration of Tryptophan-Kynurenine Pathway, Acute Decompensation, and Acute-on-Chronic Liver Failure in Cirrhosis. Hepatology 2019; 69:1686-1701. [PMID: 30521097 DOI: 10.1002/hep.30363] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/19/2018] [Accepted: 10/22/2018] [Indexed: 12/12/2022]
Abstract
Systemic inflammation (SI) is involved in the pathogenesis of acute decompensation (AD) and acute-on-chronic liver failure (ACLF) in cirrhosis. In other diseases, SI activates tryptophan (Trp) degradation through the kynurenine pathway (KP), giving rise to metabolites that contribute to multiorgan/system damage and immunosuppression. In the current study, we aimed to characterize the KP in patients with cirrhosis, in whom this pathway is poorly known. The serum levels of Trp, key KP metabolites (kynurenine and kynurenic and quinolinic acids), and cytokines (SI markers) were measured at enrollment in 40 healthy subjects, 39 patients with compensated cirrhosis, 342 with AD (no ACLF) and 180 with ACLF, and repeated in 258 patients during the 28-day follow-up. Urine KP metabolites were measured in 50 patients with ACLF. Serum KP activity was normal in compensated cirrhosis, increased in AD and further increased in ACLF, in parallel with SI; it was remarkably higher in ACLF with kidney failure than in ACLF without kidney failure in the absence of differences in urine KP activity and fractional excretion of KP metabolites. The short-term course of AD and ACLF (worsening, improvement, stable) correlated closely with follow-up changes in serum KP activity. Among patients with AD at enrollment, those with the highest baseline KP activity developed ACLF during follow-up. Among patients who had ACLF at enrollment, those with immune suppression and the highest KP activity, both at baseline, developed nosocomial infections during follow-up. Finally, higher baseline KP activity independently predicted mortality in patients with AD and ACLF. Conclusion: Features of KP activation appear in patients with AD, culminate in patients with ACLF, and may be involved in the pathogenesis of ACLF, clinical course, and mortality.
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Affiliation(s)
- Joan Clària
- European Foundation for the Study of Chronic Liver Failure Consortium and Grifols Chair, Barcelona, Spain.,Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure Consortium and Grifols Chair, Barcelona, Spain.,Inserm, Centre de Recherche sur l'Inflammation, Université Paris Diderot-Paris, Département Hospitalo-Universitaire UNITY; Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris; Laboratoire d'Excellence Inflamex, ComUE Sorbonne Paris Cité, Paris, France
| | - François Fenaille
- CEA, INRA, Université Paris Saclay, Laboratoire d'Etude du Métabolisme des Médicaments, MetaboHUB-Paris, Gif-Sur-Yvette, France
| | - Alex Amorós
- European Foundation for the Study of Chronic Liver Failure Consortium and Grifols Chair, Barcelona, Spain
| | - Christophe Junot
- CEA, INRA, Université Paris Saclay, Laboratoire d'Etude du Métabolisme des Médicaments, MetaboHUB-Paris, Gif-Sur-Yvette, France
| | - Henning Gronbaek
- Department of Hepatology & Gastroenterology, Aarhus University Hospital, Aarhus, Denmark
| | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Alain Pruvost
- CEA, INRA Université Paris Saclay, Service de Pharmacologie et Immunoanalyse, Plateforme SMArt-MS, Gif-sur-Yvette, France
| | - Aurélie Ghettas
- CEA, INRA Université Paris Saclay, Service de Pharmacologie et Immunoanalyse, Plateforme SMArt-MS, Gif-sur-Yvette, France
| | - Emeline Chu-Van
- CEA, INRA, Université Paris Saclay, Laboratoire d'Etude du Métabolisme des Médicaments, MetaboHUB-Paris, Gif-Sur-Yvette, France
| | | | - Karl Oettl
- Medical University of Graz, Graz, Austria
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino, Italy
| | - Jonel Trebicka
- European Foundation for the Study of Chronic Liver Failure Consortium and Grifols Chair, Barcelona, Spain.,Department of Internal Medicine I, University of Bonn, Bonn, Germany.,J.W. Goethe University Hospital, Frankfurt, Germany
| | - Marco Pavesi
- European Foundation for the Study of Chronic Liver Failure Consortium and Grifols Chair, Barcelona, Spain
| | - Carme Deulofeu
- European Foundation for the Study of Chronic Liver Failure Consortium and Grifols Chair, Barcelona, Spain
| | | | - Thierry Gustot
- CUB Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Javier Fernández
- European Foundation for the Study of Chronic Liver Failure Consortium and Grifols Chair, Barcelona, Spain.,Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | | | - Faouzi Saliba
- Hôpital Paul Brousse, Université Paris-Sud, Villejuif, France
| | - Noémie Butin
- CEA, INRA, Université Paris Saclay, Laboratoire d'Etude du Métabolisme des Médicaments, MetaboHUB-Paris, Gif-Sur-Yvette, France
| | - Benoit Colsch
- CEA, INRA, Université Paris Saclay, Laboratoire d'Etude du Métabolisme des Médicaments, MetaboHUB-Paris, Gif-Sur-Yvette, France
| | - Christophe Moreno
- CUB Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - François Durand
- Inserm, Centre de Recherche sur l'Inflammation, Université Paris Diderot-Paris, Département Hospitalo-Universitaire UNITY; Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris; Laboratoire d'Excellence Inflamex, ComUE Sorbonne Paris Cité, Paris, France
| | | | - Rafael Bañares
- Facultad de Medicina, Universidad Complutense, Madrid, Spain
| | | | - Pere Ginès
- Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Alexander Gerbes
- Department of Medicine II, University Hospital LMU Munich, Liver Center Munich, Munich, Germany
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London, United Kingdom
| | - Paolo Angeli
- European Foundation for the Study of Chronic Liver Failure Consortium and Grifols Chair, Barcelona, Spain.,Unit of Internal Medicine and Hepatology, Department of Medicine, DIMED, University of Padova, Padoa, Italy
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure Consortium and Grifols Chair, Barcelona, Spain
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19
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Trebicka J, Amoros A, Pitarch C, Titos E, Alcaraz-Quiles J, Schierwagen R, Deulofeu C, Fernandez-Gomez J, Piano S, Caraceni P, Oettl K, Sola E, Laleman W, McNaughtan J, Mookerjee RP, Coenraad MJ, Welzel T, Steib C, Garcia R, Gustot T, Rodriguez Gandia MA, Bañares R, Albillos A, Zeuzem S, Vargas V, Saliba F, Nevens F, Alessandria C, de Gottardi A, Zoller H, Ginès P, Sauerbruch T, Gerbes A, Stauber RE, Bernardi M, Angeli P, Pavesi M, Moreau R, Clària J, Jalan R, Arroyo V. Addressing Profiles of Systemic Inflammation Across the Different Clinical Phenotypes of Acutely Decompensated Cirrhosis. Front Immunol 2019; 10:476. [PMID: 30941129 PMCID: PMC6434999 DOI: 10.3389/fimmu.2019.00476] [Citation(s) in RCA: 111] [Impact Index Per Article: 22.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2018] [Accepted: 02/21/2019] [Indexed: 12/16/2022] Open
Abstract
Background: Patients with acutely decompensated cirrhosis (AD) may or may not develop acute-on-chronic liver failure (ACLF). ACLF is characterized by high-grade systemic inflammation, organ failures (OF) and high short-term mortality. Although patients with AD cirrhosis exhibit distinct clinical phenotypes at baseline, they have low short-term mortality, unless ACLF develops during follow-up. Because little is known about the association of profile of systemic inflammation with clinical phenotypes of patients with AD cirrhosis, we aimed to investigate a battery of markers of systemic inflammation in these patients. Methods: Upon hospital admission baseline plasma levels of 15 markers (cytokines, chemokines, and oxidized albumin) were measured in 40 healthy controls, 39 compensated cirrhosis, 342 AD cirrhosis, and 161 ACLF. According to EASL-CLIF criteria, AD cirrhosis was divided into three distinct clinical phenotypes (AD-1: Creatinine<1.5, no HE, no OF; AD-2: creatinine 1.5-2, and or HE grade I/II, no OF; AD-3: Creatinine<1.5, no HE, non-renal OF). Results: Most markers were slightly abnormal in compensated cirrhosis, but markedly increased in AD. Patients with ACLF exhibited the largest number of abnormal markers, indicating "full-blown" systemic inflammation (all markers). AD-patients exhibited distinct systemic inflammation profiles across three different clinical phenotypes. In each phenotype, activation of systemic inflammation was only partial (30% of the markers). Mortality related to each clinical AD-phenotype was significantly lower than mortality associated with ACLF (p < 0.0001 by gray test). Among AD-patients baseline systemic inflammation (especially IL-8, IL-6, IL-1ra, HNA2 independently associated) was more intense in those who had poor 28-day outcomes (ACLF, death) than those who did not experience these outcomes. Conclusions: Although AD-patients exhibit distinct profiles of systemic inflammation depending on their clinical phenotypes, all these patients have only partial activation of systemic inflammation. However, those with the most extended baseline systemic inflammation had the highest the risk of ACLF development and death.
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Affiliation(s)
- Jonel Trebicka
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Department of Internal Medicine I, University of Bonn, Bonn, Germany.,Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.,Department of Mechanical Biology, Institute for Bioengineering of Catalonia, Barcelona, Spain.,J.W. Goethe University Hospital, Frankfurt, Germany
| | - Alex Amoros
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Carla Pitarch
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Esther Titos
- Department of Biochemistry and Molecular Genetics, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - José Alcaraz-Quiles
- Department of Biochemistry and Molecular Genetics, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Robert Schierwagen
- Department of Internal Medicine I, University of Bonn, Bonn, Germany.,J.W. Goethe University Hospital, Frankfurt, Germany
| | - Carmen Deulofeu
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | | | - Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Karl Oettl
- Department of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Elsa Sola
- Liver Unit, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Wim Laleman
- University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | | | | | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, Netherlands
| | - Tania Welzel
- J.W. Goethe University Hospital, Frankfurt, Germany
| | - Christian Steib
- Department of Medicine II, Liver Center Munich, University Hospital LMU Munich, Munich, Germany
| | - Rita Garcia
- Department of Digestive Diseases and CIBERehd, Facultad de Medicina, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | - Thierry Gustot
- Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Rafael Bañares
- Department of Digestive Diseases and CIBERehd, Facultad de Medicina, Hospital General Universitario Gregorio Marañón, Instituto de Investigación Sanitaria Gregorio Marañón, Universidad Complutense, Madrid, Spain
| | | | | | | | - Faouzi Saliba
- Hôpital Paul Brousse, Université Paris-Sud, Villejuif, France
| | - Frederic Nevens
- University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino, Italy
| | | | - Heinz Zoller
- Department of Hepatology and Gastroenterology, University Clinic Innsbruck, Innsbruck, Austria
| | - Pere Ginès
- Liver Unit, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Tilman Sauerbruch
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Alexander Gerbes
- Department of Medicine II, Liver Center Munich, University Hospital LMU Munich, Munich, Germany
| | - Rudolf E Stauber
- Department of Gastroenterology and Hepatology, Medical University of Graz, Graz, Austria
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Marco Pavesi
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Richard Moreau
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Inserm, U1149, Centre de Recherche sur l'Inflammation (CRI), UMRS1149, Paris, France.,Université Paris Diderot-Paris 7, Département Hospitalo-Universitaire (DHU) UNITY, Paris, France.,Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Paris, France.,Laboratoire d'Excellence Inflamex, ComUE Sorbonne Paris Cité, Paris, France
| | - Joan Clària
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.,Department of Biochemistry and Molecular Genetics, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | | | - Vicente Arroyo
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
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20
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Fernández J, Prado V, Trebicka J, Amoros A, Gustot T, Wiest R, Deulofeu C, Garcia E, Acevedo J, Fuhrmann V, Durand F, Sánchez C, Papp M, Caraceni P, Vargas V, Bañares R, Piano S, Janicko M, Albillos A, Alessandria C, Soriano G, Welzel TM, Laleman W, Gerbes A, De Gottardi A, Merli M, Coenraad M, Saliba F, Pavesi M, Jalan R, Ginès P, Angeli P, Arroyo V. Multidrug-resistant bacterial infections in patients with decompensated cirrhosis and with acute-on-chronic liver failure in Europe. J Hepatol 2019. [PMID: 30391380 DOI: 10.1016/j.jhep.2018.10.02710.1016/j.jhep.2018.10.027] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/24/2023]
Abstract
BACKGROUND & AIMS Antibiotic resistance has been increasingly reported in patients with decompensated cirrhosis in single-center studies. Prospective investigations reporting broad epidemiological data are scarce. We aimed to analyze epidemiological changes in bacterial infections in patients with decompensated cirrhosis. METHODS This was a prospective evaluation of 2 series of patients hospitalized with decompensated cirrhosis. The Canonic series included 1,146 patients from Northern, Southern and Western Europe in 2011. Data on epidemiology, clinical characteristics of bacterial infections, microbiology and empirical antibiotic schedules were assessed. A second series of 883 patients from Eastern, Southern and Western Europe was investigated between 2017-2018. RESULTS A total of 455 patients developed 520 infections (39.7%) in the first series, with spontaneous bacterial peritonitis, urinary tract infections and pneumonia the most frequent infections. Nosocomial episodes predominated in this series. Nearly half of the infections were culture-positive, of which 29.2% were caused by multidrug-resistant organisms (MDROs). MDR strains were more frequently isolated in Northern and Western Europe. Extended-spectrum beta-lactamase-producing Enterobacteriaceae were the most frequent MDROs isolated in this series, although prevalence and type differed markedly among countries and centers. Antibiotic resistance was associated with poor prognosis and failure of antibiotic strategies, based on third-generation cephalosporins or quinolones. Nosocomial infection (odds ratio [OR] 2.74; p < 0.001), intensive care unit admission (OR 2.09; p = 0.02), and recent hospitalization (OR 1.93; p = 0.04) were identified as independent predictors of MDR infection. The prevalence of MDROs in the second series (392 infections/284 patients) was 23%; 38% in culture-positive infections. A mild increase in the rate of carbapenem-resistant Enterobacteriaceae was observed in this series. CONCLUSIONS MDR bacterial infections constitute a prevalent, growing and complex healthcare problem in patients with decompensated cirrhosis and acute-on-chronic liver failure across Europe, negatively impacting on prognosis. Strategies aimed at preventing the spread of antibiotic resistance in cirrhosis should be urgently evaluated. LAY SUMMARY Infections caused by bacteria resistant to the main antibiotic families are prevalent in patients with cirrhosis. This study demonstrates that this healthcare problem is increasing and extends through all European regions. Infections caused by these difficult to treat bacteria resolve less frequently and often cause the death of the patient. The type of resistant bacteria varies markedly among different hospitals.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain.
| | - Verónica Prado
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jonel Trebicka
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; University of Bonn, Germany
| | - Alex Amoros
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Thierry Gustot
- Liver Transplant Unit, Erasme Hospital, Brussels, Belgium
| | - Reiner Wiest
- Department of Medicine and Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Carme Deulofeu
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Elisabet Garcia
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | | | | | | | - Cristina Sánchez
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Maria Papp
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Hungary
| | | | - Victor Vargas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital Vall d'Hebron, Barcelona, Spain
| | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital Gregorio Marañon, Madrid, Spain
| | | | | | | | | | - German Soriano
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital of Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Alexander Gerbes
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU Munich, Germany
| | - Andrea De Gottardi
- Department of Medicine and Surgery, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Faouzi Saliba
- Centre Hepato-Biliare, Hòpital Paul Brousse, Paris, France
| | - Marco Pavesi
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Rajiv Jalan
- ILDH, Division of Medicine, University College London Medical School, London, United Kingdom
| | - Pere Ginès
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain
| | | | - Vicente Arroyo
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | | |
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21
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Fernández J, Prado V, Trebicka J, Amoros A, Gustot T, Wiest R, Deulofeu C, Garcia E, Acevedo J, Fuhrmann V, Durand F, Sánchez C, Papp M, Caraceni P, Vargas V, Bañares R, Piano S, Janicko M, Albillos A, Alessandria C, Soriano G, Welzel TM, Laleman W, Gerbes A, De Gottardi A, Merli M, Coenraad M, Saliba F, Pavesi M, Jalan R, Ginès P, Angeli P, Arroyo V. Multidrug-resistant bacterial infections in patients with decompensated cirrhosis and with acute-on-chronic liver failure in Europe. J Hepatol 2019; 70:398-411. [PMID: 30391380 DOI: 10.1016/j.jhep.2018.10.027] [Citation(s) in RCA: 185] [Impact Index Per Article: 37.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2018] [Revised: 10/23/2018] [Accepted: 10/28/2018] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS Antibiotic resistance has been increasingly reported in patients with decompensated cirrhosis in single-center studies. Prospective investigations reporting broad epidemiological data are scarce. We aimed to analyze epidemiological changes in bacterial infections in patients with decompensated cirrhosis. METHODS This was a prospective evaluation of 2 series of patients hospitalized with decompensated cirrhosis. The Canonic series included 1,146 patients from Northern, Southern and Western Europe in 2011. Data on epidemiology, clinical characteristics of bacterial infections, microbiology and empirical antibiotic schedules were assessed. A second series of 883 patients from Eastern, Southern and Western Europe was investigated between 2017-2018. RESULTS A total of 455 patients developed 520 infections (39.7%) in the first series, with spontaneous bacterial peritonitis, urinary tract infections and pneumonia the most frequent infections. Nosocomial episodes predominated in this series. Nearly half of the infections were culture-positive, of which 29.2% were caused by multidrug-resistant organisms (MDROs). MDR strains were more frequently isolated in Northern and Western Europe. Extended-spectrum beta-lactamase-producing Enterobacteriaceae were the most frequent MDROs isolated in this series, although prevalence and type differed markedly among countries and centers. Antibiotic resistance was associated with poor prognosis and failure of antibiotic strategies, based on third-generation cephalosporins or quinolones. Nosocomial infection (odds ratio [OR] 2.74; p < 0.001), intensive care unit admission (OR 2.09; p = 0.02), and recent hospitalization (OR 1.93; p = 0.04) were identified as independent predictors of MDR infection. The prevalence of MDROs in the second series (392 infections/284 patients) was 23%; 38% in culture-positive infections. A mild increase in the rate of carbapenem-resistant Enterobacteriaceae was observed in this series. CONCLUSIONS MDR bacterial infections constitute a prevalent, growing and complex healthcare problem in patients with decompensated cirrhosis and acute-on-chronic liver failure across Europe, negatively impacting on prognosis. Strategies aimed at preventing the spread of antibiotic resistance in cirrhosis should be urgently evaluated. LAY SUMMARY Infections caused by bacteria resistant to the main antibiotic families are prevalent in patients with cirrhosis. This study demonstrates that this healthcare problem is increasing and extends through all European regions. Infections caused by these difficult to treat bacteria resolve less frequently and often cause the death of the patient. The type of resistant bacteria varies markedly among different hospitals.
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Affiliation(s)
- Javier Fernández
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain.
| | - Verónica Prado
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain
| | - Jonel Trebicka
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; University of Bonn, Germany
| | - Alex Amoros
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Thierry Gustot
- Liver Transplant Unit, Erasme Hospital, Brussels, Belgium
| | - Reiner Wiest
- Department of Medicine and Surgery, Inselspital, University of Bern, Bern, Switzerland
| | - Carme Deulofeu
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Elisabet Garcia
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | | | | | | | - Cristina Sánchez
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Maria Papp
- Department of Internal Medicine, Division of Gastroenterology, Faculty of Medicine, University of Debrecen, Hungary
| | | | - Victor Vargas
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital Vall d'Hebron, Barcelona, Spain
| | - Rafael Bañares
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital Gregorio Marañon, Madrid, Spain
| | | | | | | | | | - German Soriano
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain; Hospital of Santa Creu i Sant Pau, Barcelona, Spain
| | | | | | - Alexander Gerbes
- Department of Medicine II, Liver Centre Munich, University Hospital, LMU Munich, Germany
| | - Andrea De Gottardi
- Department of Medicine and Surgery, Inselspital, University of Bern, Bern, Switzerland
| | | | | | - Faouzi Saliba
- Centre Hepato-Biliare, Hòpital Paul Brousse, Paris, France
| | - Marco Pavesi
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
| | - Rajiv Jalan
- ILDH, Division of Medicine, University College London Medical School, London, United Kingdom
| | - Pere Ginès
- Liver ICU, Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), ISCIII, Spain
| | | | - Vicente Arroyo
- European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain
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22
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Ardelt MA, Fröhlich T, Martini E, Müller M, Kanitz V, Atzberger C, Cantonati P, Meßner M, Posselt L, Lehr T, Wojtyniak J, Ulrich M, Arnold GJ, König L, Parazzoli D, Zahler S, Rothenfußer S, Mayr D, Gerbes A, Scita G, Vollmar AM, Pachmayr J. Inhibition of Cyclin-Dependent Kinase 5: A Strategy to Improve Sorafenib Response in Hepatocellular Carcinoma Therapy. Hepatology 2019; 69:376-393. [PMID: 30033593 PMCID: PMC6590289 DOI: 10.1002/hep.30190] [Citation(s) in RCA: 36] [Impact Index Per Article: 7.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2018] [Accepted: 07/08/2018] [Indexed: 12/29/2022]
Abstract
Therapeutic options for patients with advanced-stage hepatocellular carcinoma (HCC) are very limited. The only approved first-line treatment is the multi-tyrosine kinase inhibitor sorafenib, which shows low response rates and severe side effects. In particular, the compensatory activation of growth factor receptors leads to chemoresistance and limits the clinical impact of sorafenib. However, combination approaches to improve sorafenib have failed. Here we investigate the inhibition of cyclin-dependent kinase 5 (Cdk5) as a promising combination strategy to improve sorafenib response in HCC. Combination of sorafenib with Cdk5 inhibition (genetic knockdown by short hairpin RNA or CRISPR/Cas9 and pharmacologic inhibition) synergistically impaired HCC progression in vitro and in vivo by inhibiting both tumor cell proliferation and migration. Importantly, these effects were mediated by a mechanism for Cdk5: A liquid chromatography-tandem mass spectrometry-based proteomic approach revealed that Cdk5 inhibition interferes with intracellular trafficking, a process crucial for cellular homeostasis and growth factor receptor signaling. Cdk5 inhibition resulted in an accumulation of enlarged vesicles and respective cargos in the perinuclear region, considerably impairing the extent and quality of growth factor receptor signaling. Thereby, Cdk5 inhibition offers a comprehensive approach to globally disturb growth factor receptor signaling that is superior to specific inhibition of individual growth factor receptors. Conclusion: Cdk5 inhibition represents an effective approach to improve sorafenib response and to prevent sorafenib treatment escape in HCC. Notably, Cdk5 is an addressable target frequently overexpressed in HCC, and with Dinaciclib, a clinically tested Cdk5 inhibitor is readily available. Thus, our study provides evidence for clinically evaluating the combination of sorafenib and Dinaciclib to improve the therapeutic situation for patients with advanced-stage HCC.
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Affiliation(s)
- Maximilian A. Ardelt
- Department of Pharmacy, Pharmaceutical BiologyLMU MunichMunichGermany,Institute of PharmacyParacelsus Medical UniversitySalzburgAustria
| | - Thomas Fröhlich
- Laboratory for Functional Genome Analysis, LAFUGA, Gene CentreUniversity of MunichMunichGermany
| | - Emanuele Martini
- IFOM‐FIRC Institute of Molecular OncologyDepartment of Oncology and Hemato‐OncologyUniversity of MilanMilanItalyMilanItaly
| | - Martin Müller
- Department of Pharmacy, Pharmaceutical BiologyLMU MunichMunichGermany
| | - Veronika Kanitz
- Institute of PathologyLudwig Maximilians University of MunichMunichGermany
| | - Carina Atzberger
- Department of Pharmacy, Pharmaceutical BiologyLMU MunichMunichGermany
| | - Petra Cantonati
- Institute of PharmacyParacelsus Medical UniversitySalzburgAustria
| | - Martina Meßner
- Department of Pharmacy, Pharmaceutical BiologyLMU MunichMunichGermany,Institute of PharmacyParacelsus Medical UniversitySalzburgAustria
| | - Laura Posselt
- Center of Integrated Protein Science Munich (CIPS‐M) and Division of Clinical Pharmacology, Department of Internal Medicine IVKlinikum der Universität MünchenMunichGermany
| | - Thorsten Lehr
- Clinical PharmacySaarland UniversitySaarbrückenGermany
| | | | - Melanie Ulrich
- Department of Pharmacy, Pharmaceutical BiologyLMU MunichMunichGermany
| | - Georg J. Arnold
- Laboratory for Functional Genome Analysis, LAFUGA, Gene CentreUniversity of MunichMunichGermany
| | - Lars König
- Center of Integrated Protein Science Munich (CIPS‐M) and Division of Clinical Pharmacology, Department of Internal Medicine IVKlinikum der Universität MünchenMunichGermany
| | - Dario Parazzoli
- IFOM‐FIRC Institute of Molecular OncologyDepartment of Oncology and Hemato‐OncologyUniversity of MilanMilanItalyMilanItaly
| | - Stefan Zahler
- Department of Pharmacy, Pharmaceutical BiologyLMU MunichMunichGermany
| | - Simon Rothenfußer
- Center of Integrated Protein Science Munich (CIPS‐M) and Division of Clinical Pharmacology, Department of Internal Medicine IVKlinikum der Universität MünchenMunichGermany
| | - Doris Mayr
- Institute of PathologyLudwig Maximilians University of MunichMunichGermany
| | - Alexander Gerbes
- Department of Medicine 2, Liver Center MunichUniversity Hospital, LMU MunichMunichGermany
| | - Giorgio Scita
- IFOM‐FIRC Institute of Molecular OncologyDepartment of Oncology and Hemato‐OncologyUniversity of MilanMilanItalyMilanItaly
| | | | - Johanna Pachmayr
- Department of Pharmacy, Pharmaceutical BiologyLMU MunichMunichGermany,Institute of PharmacyParacelsus Medical UniversitySalzburgAustria
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Piano S, Schmidt HH, Ariza X, Amoros A, Romano A, Hüsing-Kabar A, Solà E, Gerbes A, Bernardi M, Alessandria C, Scheiner B, Tonon M, Maschmeier M, Solè C, Trebicka J, Gustot T, Nevens F, Arroyo V, Gines P, Angeli P. Association Between Grade of Acute on Chronic Liver Failure and Response to Terlipressin and Albumin in Patients With Hepatorenal Syndrome. Clin Gastroenterol Hepatol 2018; 16:1792-1800.e3. [PMID: 29391267 DOI: 10.1016/j.cgh.2018.01.035] [Citation(s) in RCA: 100] [Impact Index Per Article: 16.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2017] [Revised: 01/12/2018] [Accepted: 01/21/2018] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Type 1 hepatorenal syndrome (HRS) is the most high-risk type of renal failure in patients with cirrhosis. Terlipressin and albumin are effective treatments for type 1 HRS. However, the effects of acute on chronic liver failure (ACLF) grade on response to treatment are not clear. We aimed to identify factors associated with response to treatment with terlipressin and albumin in patients with type 1 HRS (reduction in serum level of creatinine to below 1.5 mg/dL at the end of treatment) and factors associated with death within 90 days of HRS diagnosis (90-day mortality). METHODS We performed a retrospective analysis of 4 different cohorts of consecutive patients with HRS treated with terlipressin and albumin from February 2007 through January 2016 at medical centers in Europe (total, 298 patients). We analyzed demographic, clinical, and laboratory data collected before and during treatment; patients were followed until death, liver transplantation, or 90 days after HRS diagnosis. RESULTS Response to treatment was observed in 53% of patients. Of patients with grade 1 ACLF, 60% responded to treatment; among those with grade 2 ACLF, 48% responded, and among those with grade 3 ACLF, 29% responded (P < .001 for comparison between grades). In multivariate analysis, baseline serum level of creatinine (odds ratio, 0.23; P = .001) and ACLF grade (odds ratio, 0.63; P = .01) were independently associated with response to treatment. Patient age (hazard ratio [HR], 1.05; P < .001), white blood cell count (HR, 1.51; P = .006), ACLF grade (HR, 2.06; P < .001), and no response to treatment (HR, 0.41; P < .001) associated with 90-day mortality. CONCLUSION In a retrospective analysis of data from 4 cohorts of patients treated for type 1 HRS, we found ACLF grade to be the largest determinant of response to terlipressin and albumin. ACLF grade affects survival independently of response to treatment. New therapeutic strategies should be developed for patients with type 1 HRS and extrarenal organ failure.
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Affiliation(s)
- Salvatore Piano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED University of Padova, Padova, Italy
| | - Hartmut H Schmidt
- Klinik für Transplantationsmedizin, Universitätsklinikum Münster, Münster, Germany
| | - Xavier Ariza
- Liver Unit, Hospital Clìnic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; 5 - Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Alex Amoros
- EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain
| | - Antonietta Romano
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED University of Padova, Padova, Italy
| | - Anna Hüsing-Kabar
- Klinik für Transplantationsmedizin, Universitätsklinikum Münster, Münster, Germany
| | - Elsa Solà
- Liver Unit, Hospital Clìnic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; 5 - Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Alexander Gerbes
- Department of Medicine II, University Hospital LMU Munich, Liver Center Munich, Munich, Germany
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino, Italy
| | - Bernhard Scheiner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Marta Tonon
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED University of Padova, Padova, Italy
| | - Miriam Maschmeier
- Klinik für Transplantationsmedizin, Universitätsklinikum Münster, Münster, Germany
| | - Cristina Solè
- Liver Unit, Hospital Clìnic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; 5 - Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain
| | - Jonel Trebicka
- EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain; Department of Internal Medicine I, University of Bonn, Bonn, Germany; Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark; Institute for Bioengineering of Catalonia, Barcelona, Spain
| | - Thierry Gustot
- Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Frederik Nevens
- University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Vicente Arroyo
- EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain
| | - Pere Gines
- Liver Unit, Hospital Clìnic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi I Sunyer, Barcelona, Spain; 5 - Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain; EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine - DIMED University of Padova, Padova, Italy.
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24
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Englschalk C, Eser D, Jox RJ, Gerbes A, Frey L, Dubay DA, Angele M, Stangl M, Meiser B, Werner J, Guba M. Benefit in liver transplantation: a survey among medical staff, patients, medical students and non-medical university staff and students. BMC Med Ethics 2018; 19:7. [PMID: 29433496 PMCID: PMC5810023 DOI: 10.1186/s12910-018-0248-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Accepted: 01/29/2018] [Indexed: 12/23/2022] Open
Abstract
Background The allocation of any scarce health care resource, especially a lifesaving resource, can create profound ethical and legal challenges. Liver transplant allocation currently is based upon urgency, a sickest-first approach, and does not utilize capacity to benefit. While urgency can be described reasonably well with the MELD system, benefit encompasses multiple dimensions of patients’ well-being. Currently, the balance between both principles is ill-defined. Methods This survey with 502 participants examines how urgency and benefit are weighted by different stakeholders (medical staff, patients on the liver transplant list or already transplanted, medical students and non-medical university staff and students). Results Liver transplant patients favored the sickest-first allocation, although all other groups tended to favor benefit. Criteria of a successful transplantation were a minimum survival of at least 1 year and recovery of functional status to being ambulatory and capable of all self-care (ECOG 2). An individual delisting decision was accepted when the 1-year survival probability would fall below 50%. Benefit was found to be a critical variable that may also trigger the willingness to donate organs. Conclusions The strong interest of stakeholder for successful liver transplants is inadequately translated into current allocation rules.
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Affiliation(s)
- Christine Englschalk
- Department of General, Visceral, Vascular and Transplant Surgery, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Daniela Eser
- Department of Psychiatry and Psychotherapy, Klinikum der Universität München, Nußbaumstraße 7, 80336, München, Germany
| | - Ralf J Jox
- Institute of Ethics, History and Theory of Medicine, LMU Munich, Lessingstr. 2, 80336, München, Germany
| | - Alexander Gerbes
- Department of Medicine II, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Lorenz Frey
- Department of Anesthesiology, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Derek A Dubay
- Department of Surgery, Division of Transplant Surgery, Medical University of South Carolina, 96 Jonathan Lucas Street, Charleston, SC, 29425, USA
| | - Martin Angele
- Department of General, Visceral, Vascular and Transplant Surgery, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Manfred Stangl
- Department of General, Visceral, Vascular and Transplant Surgery, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Bruno Meiser
- Transplant Center Munich, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Jens Werner
- Department of General, Visceral, Vascular and Transplant Surgery, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany
| | - Markus Guba
- Department of General, Visceral, Vascular and Transplant Surgery, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany. .,Transplant Center Munich, Klinikum der Universität München, Marchioninistrasse 15, 81377, München, Germany.
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25
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Gerbes A, Zoulim F, Tilg H, Dufour J, Bruix J, Paradis V, Salem R, Peck–Radosavljevic M, Galle PR, Greten TF, Nault J, Avila MA. Gut roundtable meeting paper: selected recent advances in hepatocellular carcinoma. Gut 2018; 67:380-388. [PMID: 29150490 PMCID: PMC6309825 DOI: 10.1136/gutjnl-2017-315068] [Citation(s) in RCA: 109] [Impact Index Per Article: 18.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/16/2017] [Revised: 10/03/2017] [Accepted: 10/11/2017] [Indexed: 12/12/2022]
Abstract
Hepatocellular carcinoma (HCC) ranks number three among the most frequent causes of death from solid tumors worldwide. With obesity and fatty liver diseases as risk factors on the rise, HCC represents an ever increasing challenge. While there is still no curative treatment for most patients numerous novel drugs have been proposed, but most ultimately failed in phase III trials. This manuscript targets therapeutic advances and most burning issues. Expert key point summaries and urgent research agenda are provided regarding risk factors, including microbiota, need for prognostic and predictive biomarkers and the equivocal role of liver biopsy. Therapeutic topics highlighted are locoregional techniques, combination therapies and the potential of immunotherapy. Finally the manuscript provides a critical evaluation of novel targets and strategies for personalized treatment of HCC.
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Affiliation(s)
- Alexander Gerbes
- Department of Medicine 2, Liver Center Munich, University Hospital, LMU, Munich, Germany
| | - Fabien Zoulim
- Hepatology Department at the Hospices Civils de Lyon, Lyon University, Institut Universitaire de France, Lyon, France
- Viral Hepatitis Team, Cancer Research Center of Lyon (CRCL), INSERM, Lyon University, Lyon, France
| | - Herbert Tilg
- Department of Internal Medicine I, Gastroenterology, Hepatology & Endocrinology, Innsbruck Medical University, Innsbruck, Austria
| | - Jean–François Dufour
- Hepatology, Department of Clinical Research, University of Bern, Bern, Switzerland
- University Clinic of Visceral Surgery and Medicine, Inselspital Bern, Bern, Switzerland
| | - Jordi Bruix
- BCLC Group, Liver Unit, Hospital Clínic, Universitat de Barcelona, IDIBAPS, CIBEREHD, Barcelona, Spain
| | - Valérie Paradis
- Pathology Department Beaujon Hospital & INSERM, INSERM 1149, University Paris–Diderot, Paris, France
| | - Riad Salem
- Department of Radiology, Section of Vascular and Interventional Radiology, Northwestern University, Chicago, Illinois, USA
| | - Markus Peck–Radosavljevic
- Department of Gastroenterology & Hepatology, Endocrinology and Nephrology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Peter R Galle
- Department of Internal Medicine, University Medical Center I, Mainz, Germany
| | - Tim F Greten
- National Cancer Institute, Center for Cancer Research, National Institutes of Health, Bethesda, Maryland, USA
- Gastrointestinal Malignancy Section, Thoracic and GI Oncology Branch, Center for Cancer Research, Bethesda, Maryland, USA
| | - Jean–Charles Nault
- Unité Mixte de Recherche 1162, Génomique fonctionnelle des tumeurs solides, Institut National de la Santé et de la Recherche Médicale, Paris, France
- Liver unit, Hôpital Jean Verdier, Hôpitaux Universitaires Paris–Seine–Saint–Denis, Assistance–Publique Hôpitaux de Paris, Paris, France
- Unité de Formation et de Recherche Santé Médecine et Biologie Humaine, Université Paris 13, Communauté d’Universités et Etablissements Sorbonne Paris Cité, Paris, France
| | - Matias A Avila
- Programme of Hepatology, CIMA, IdiSNA, CIBERehd, University of Navarra, Pamplona, Spain
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26
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Münch S, Habermehl D, Agha A, Belka C, Combs SE, Eckel R, Friess H, Gerbes A, Nüssler NC, Schepp W, Schmid RM, Schmitt W, Schubert-Fritschle G, Weber B, Werner J, Engel J. Perioperative chemotherapy vs. neoadjuvant chemoradiation in gastroesophageal junction adenocarcinoma : A population-based evaluation of the Munich Cancer Registry. Strahlenther Onkol 2017; 194:125-135. [PMID: 29071366 DOI: 10.1007/s00066-017-1225-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2017] [Accepted: 10/05/2017] [Indexed: 01/03/2023]
Abstract
BACKGROUND To date, it remains unclear whether locally advanced adenocarcinoma of the gastroesophageal junction (AEG) should be treated with neoadjuvant chemoradiation (nCRT), analogous to esophageal cancer, or with perioperative chemotherapy (pCT), analogous to gastric cancer. The purpose of this study was to analyze the data of the Munich Cancer Registry (MCR) and to compare pCT and nCRT in AEG patients. PATIENTS AND METHODS A total of 2,992 AEG patients, treated between 1998 and 2014, were included in the study. Baseline and tumor parameters as well as overall survival (OS) and tumor recurrence were compared between 56 patients undergoing nCRT and 64 patients undergoing pCT with UICC stage II/III cancer. In addition, uni- and multivariate analyses using Cox regression models were performed to evaluate the effect of tumor characteristics and treatment regimens on OS. RESULTS In patients with UICC stage II/III AEG treated with either nCRT or pCT, no significant differences were seen for baseline and tumor characteristics. While there was a significantly higher cumulative incidence of locoregional treatment failure after pCT (32.8%; 95% CI: 18.0-48.4%) compared with nCRT (7.4%; 95% CI: 2.3-16.5%; p = 0.007), there was no significant difference for distant treatment failure (52.9%; 95% CI: 35.4-67.7% and 38.4%; 95% CI: 23.7-52.9%; p = 0.347). When analyzing the whole cohort, patients who received pCT were younger (58.3 years vs. 63.0 years; p = 0.016), had a higher chance of complete tumor resection (81% vs. 67%; p = 0.033), more resected lymph nodes (p = 0.036), and fewer lymph node metastases (p = 0.038) compared with patients who received nCRT. Nevertheless, there was still a strong trend toward a higher incidence of local treatment failure after pCT (25.8%; 95% CI: 14.7-38.3% vs. 12.6%; 95% CI: 5.5-22.8%; p = 0.053). Comparable to the results for patients with UICC stage II/III, no difference was seen for the incidence of distant treatment failure. When excluding patients with UICC stage IV cancer, no significant difference was found for OS. CONCLUSION For UICC stage II/III carcinoma, nCRT was associated with an improved locoregional tumor control compared with pCT, while no further significant differences were seen between nCRT and pCT for UICC stage II/III AEG. Moreover, there was a strong trend toward improved locoregional tumor control after nCRT when analyzing all patients treated with nCRT or pCT, despite these patients having higher risk factors.
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Affiliation(s)
- Stefan Münch
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany
| | - Daniel Habermehl
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany. .,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany.
| | - Ayman Agha
- Department of Surgery, Klinikum Bogenhausen, Städtisches Klinikum München, Munich, Germany
| | - Claus Belka
- Department of Radiation Oncology, Klinikum Großhadern, Ludwig-Maximilians-University (LMU), Munich, Germany
| | - Stephanie E Combs
- Department of Radiation Oncology, Klinikum rechts der Isar, Technical University Munich, Ismaninger Str. 22, 81675, Munich, Germany.,Institute of Innovative Radiotherapy (iRT), Helmholtz Zentrum München, Ingolstädter Landstraße 1, 85764, Oberschleißheim, Germany
| | - Renate Eckel
- Munich Cancer Registry (MCR), Munich Tumour Centre (TZM), Department of Medical Informatics, Biometry and Epidemiology (IBE), Klinikum Großhadern, Ludwig Maximilians University (LMU), Munich, Germany
| | - Helmut Friess
- Department of Surgery, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Alexander Gerbes
- Department of Gastroenterology and Endocrinology, Klinikum Großhadern, Ludwig Maximilians University (LMU), Munich, Germany
| | - Natascha C Nüssler
- Department of Surgery, Klinikum Neuperlach, Städtisches Klinikum München, Munich, Germany
| | - Wolfgang Schepp
- Department of Gastroenterology, Klinikum Bogenhausen, Städtisches Klinikum München, Munich, Germany
| | - Roland M Schmid
- Department of Internal Medicine II, Klinikum rechts der Isar, Technische Universität München, Munich, Germany
| | - Wolfgang Schmitt
- Department of Gastroenterology, Klinikum Neuperlach, Städtisches Klinikum München, Munich, Germany
| | - Gabriele Schubert-Fritschle
- Munich Cancer Registry (MCR), Munich Tumour Centre (TZM), Department of Medical Informatics, Biometry and Epidemiology (IBE), Klinikum Großhadern, Ludwig Maximilians University (LMU), Munich, Germany
| | - Bernhard Weber
- Department of Internal Medicine, Klinik Bad Trissl, Oberaudorf, Germany
| | - Jens Werner
- Department of Surgery, Klinikum Großhadern, Ludwig Maximilians University (LMU), Munich, Germany
| | - Jutta Engel
- Munich Cancer Registry (MCR), Munich Tumour Centre (TZM), Department of Medical Informatics, Biometry and Epidemiology (IBE), Klinikum Großhadern, Ludwig Maximilians University (LMU), Munich, Germany
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27
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Busk TM, Møller S, Pedersen EB, Gerbes A, Krag A, Peck-Radosavljevic M, Frankova S, Coenraad MJ, Bendtsen F. Aquaporin-2 excretion in hospitalized patients with cirrhosis: Relation to development of renal insufficiency and mortality. J Gastroenterol Hepatol 2017; 32:1087-1093. [PMID: 28092112 DOI: 10.1111/jgh.13641] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2016] [Revised: 10/27/2016] [Accepted: 11/01/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIM Urinary aquaporin-2 (AQP2) is a parameter of water transport in the principal cells in the distal part of the nephron and involved in water retention in cirrhosis and may be a marker of renal function. The aim of the study was to evaluate AQP2 as a predictor of renal insufficiency and death in patients with cirrhosis. METHODS Urine samples from 199 patients (90 patients without organ failure [Group 1], 58 patients with organ failure excluding renal failure [Group 2], and 51 patients with organ failure including renal failure [Group 3]) from the CANONIC study were analyzed for urine AQP2 and urine osmolality. RESULTS There was no difference in AQP2 between the three groups. Urine osmolality was significantly lower in patients in Group 3 versus Group 1 and Group 2 (P = 0.0004). No relation was found between AQP2 and glomerular filtration rate or creatinine; however, AQP2 was a significant predictor of the development of renal insufficiency (P = 0.0485). In a univariate analysis, AQP2 was a significant predictor of 14 and 28-day survival, but this was not confirmed in multivariate analysis. CONCLUSIONS Aquaporin-2 was not associated with disease severity or markers of renal function but was a predictor for the development of renal insufficiency and death. Therefore, its future use as marker of renal insufficiency could be promising, but further research is needed before it can be considered a clinical useful tool.
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Affiliation(s)
- Troels M Busk
- Gastro Unit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark.,Centre of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Søren Møller
- Centre of Functional Imaging and Research, Department of Clinical Physiology and Nuclear Medicine, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Erling B Pedersen
- University Clinic of Nephrology and Hypertension, Aarhus University and Holstebro Hospital, Aarhus, Denmark
| | - Alexander Gerbes
- Liver Center Munich, Klinikum of the University, Ludwig Maximilian University of Munich, Munich, Germany
| | - Aleksander Krag
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Markus Peck-Radosavljevic
- Department of Gastroenterology and Hepatology, Endocrinology and Nephrology, Klinikum Klagenfurt am Wörtersee, Klagenfurt, Austria
| | - Sona Frankova
- Department of Hepatogastroenterology, Institute for Clinical and Experimental Medicine, Prague, Czech Republic
| | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Flemming Bendtsen
- Gastro Unit, Medical Division, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
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28
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Clària J, Stauber RE, Coenraad MJ, Moreau R, Jalan R, Pavesi M, Amorós À, Titos E, Alcaraz-Quiles J, Oettl K, Morales-Ruiz M, Angeli P, Domenicali M, Alessandria C, Gerbes A, Wendon J, Nevens F, Trebicka J, Laleman W, Saliba F, Welzel TM, Albillos A, Gustot T, Benten D, Durand F, Ginès P, Bernardi M, Arroyo V. Systemic inflammation in decompensated cirrhosis: Characterization and role in acute-on-chronic liver failure. Hepatology 2016; 64:1249-64. [PMID: 27483394 DOI: 10.1002/hep.28740] [Citation(s) in RCA: 472] [Impact Index Per Article: 59.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2016] [Accepted: 07/27/2016] [Indexed: 12/12/2022]
Abstract
UNLABELLED Acute-on-chronic liver failure (ACLF) in cirrhosis is characterized by acute decompensation (AD), organ failure(s), and high short-term mortality. Recently, we have proposed (systemic inflammation [SI] hypothesis) that ACLF is the expression of an acute exacerbation of the SI already present in decompensated cirrhosis. This study was aimed at testing this hypothesis and included 522 patients with decompensated cirrhosis (237 with ACLF) and 40 healthy subjects. SI was assessed by measuring 29 cytokines and the redox state of circulating albumin (HNA2), a marker of systemic oxidative stress. Systemic circulatory dysfunction (SCD) was estimated by plasma renin (PRC) and copeptin (PCC) concentrations. Measurements were performed at enrollment (baseline) in all patients and sequentially during hospitalization in 255. The main findings of this study were: (1) Patients with AD without ACLF showed very high baseline levels of inflammatory cytokines, HNA2, PRC, and PCC. Patients with ACLF showed significantly higher levels of these markers than those without ACLF; (2) different cytokine profiles were identified according to the type of ACLF precipitating event (active alcoholism/acute alcoholic hepatitis, bacterial infection, and others); (3) severity of SI and frequency and severity of ACLF at enrollment were strongly associated. The course of SI and the course of ACLF (improvement, no change, or worsening) during hospitalization and short-term mortality were also strongly associated; and (4) the strength of association of ACLF with SI was higher than with SCD. CONCLUSION These data support SI as the primary driver of ACLF in cirrhosis. (Hepatology 2016;64:1249-1264).
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Affiliation(s)
- Joan Clària
- Department of Biochemistry and Molecular Genetics, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Rudolf E Stauber
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Minneke J Coenraad
- Department of Gastroenterology and Hepatology, Leiden University Medical Center, Leiden, The Netherlands
| | - Richard Moreau
- Inserm, U1149, Centre de Recherche sur l'Inflammation (CRI), UMRS1149; Université Paris Diderot-Paris 7, Département Hospitalo-Universitaire (DHU) UNITY; Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Laboratoire d'Excellence Inflamex, ComUE Sorbonne Paris Cité, Paris, France
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London, United Kingdom
| | - Marco Pavesi
- EF-CLIF and EASL-CLIF Consortium, Barcelona, Spain
| | - Àlex Amorós
- EF-CLIF and EASL-CLIF Consortium, Barcelona, Spain
| | - Esther Titos
- Department of Biochemistry and Molecular Genetics, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - José Alcaraz-Quiles
- Department of Biochemistry and Molecular Genetics, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Karl Oettl
- Institute of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Manuel Morales-Ruiz
- Department of Biochemistry and Molecular Genetics, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology, Department of Medicine, DIMED, University of Padova, Padova, Italy
| | - Marco Domenicali
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Carlo Alessandria
- Division of Gastroenterology and Hepatology, San Giovanni Battista Hospital, Torino, Italy
| | - Alexander Gerbes
- Department of Medicine II, University Hospital LMU Munich, Liver Center Munich, Munich, Germany
| | | | - Frederik Nevens
- University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Jonel Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - Wim Laleman
- University Hospital Gasthuisberg, KU Leuven, Leuven, Belgium
| | - Faouzi Saliba
- Hôpital Paul Brousse, Université Paris-Sud, Villejuif, France
| | | | | | - Thierry Gustot
- Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | - Daniel Benten
- University Hospital Hamburg-Eppendorf, Hamburg, Germany
| | - François Durand
- Inserm, U1149, Centre de Recherche sur l'Inflammation (CRI), UMRS1149; Université Paris Diderot-Paris 7, Département Hospitalo-Universitaire (DHU) UNITY; Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Laboratoire d'Excellence Inflamex, ComUE Sorbonne Paris Cité, Paris, France
| | - Pere Ginès
- Liver Unit, Hospital Clínic, IDIBAPS and CIBERehd, Barcelona, Spain.
| | - Mauro Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
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Ariza X, Graupera I, Coll M, Solà E, Barreto R, García E, Moreira R, Elia C, Morales-Ruiz M, Llopis M, Huelin P, Solé C, Fabrellas N, Weiss E, Nevens F, Gerbes A, Trebicka J, Saliba F, Fondevila C, Hernández-Gea V, Fernández J, Bernardi M, Arroyo V, Jiménez W, Deulofeu C, Pavesi M, Angeli P, Jalan R, Moreau R, Sancho-Bru P, Ginès P. Neutrophil gelatinase-associated lipocalin is a biomarker of acute-on-chronic liver failure and prognosis in cirrhosis. J Hepatol 2016; 65:57-65. [PMID: 26988732 DOI: 10.1016/j.jhep.2016.03.002] [Citation(s) in RCA: 90] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/09/2015] [Revised: 03/03/2016] [Accepted: 03/06/2016] [Indexed: 12/30/2022]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is a syndrome that occurs in cirrhosis characterized by organ failure(s) and high mortality rate. There are no biomarkers of ACLF. The LCN2 gene and its product, neutrophil gelatinase-associated lipocalin (NGAL), are upregulated in experimental models of liver injury and cultured hepatocytes as a result of injury by toxins or proinflammatory cytokines, particularly Interleukin-6. The aim of this study was to investigate whether NGAL could be a biomarker of ACLF and whether LCN2 gene may be upregulated in the liver in ACLF. METHODS We analyzed urine and plasma NGAL levels in 716 patients hospitalized for complications of cirrhosis, 148 with ACLF. LCN2 expression was assessed in liver biopsies from 29 additional patients with decompensated cirrhosis with and without ACLF. RESULTS Urine NGAL was markedly increased in ACLF vs. no ACLF patients (108(35-400) vs. 29(12-73)μg/g creatinine; p<0.001) and was an independent predictive factor of ACLF; the independent association persisted after adjustment for kidney function or exclusion of variables present in ACLF definition. Urine NGAL was also an independent predictive factor of 28day transplant-free mortality together with MELD score and leukocyte count (AUROC 0.88(0.83-0.92)). Urine NGAL improved significantly the accuracy of MELD in predicting prognosis. The LCN2 gene was markedly upregulated in the liver of patients with ACLF. Gene expression correlated directly with serum bilirubin and INR (r=0.79; p<0.001 and r=0.67; p<0.001), MELD (r=0.68; p<0.001) and Interleukin-6 (r=0.65; p<0.001). CONCLUSIONS NGAL is a biomarker of ACLF and prognosis and correlates with liver failure and systemic inflammation. There is remarkable overexpression of LCN2 gene in the liver in ACLF syndrome. LAY SUMMARY Urine NGAL is a biomarker of acute-on-chronic liver failure (ACLF). NGAL is a protein that may be expressed in several tissues in response to injury. The protein is filtered by the kidneys due to its small size and can be measured in the urine. Ariza, Graupera and colleagues found in a series of 716 patients with cirrhosis that urine NGAL was markedly increased in patients with ACLF and correlated with prognosis. Moreover, gene coding NGAL was markedly overexpressed in the liver tissue in ACLF.
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Affiliation(s)
- X Ariza
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - I Graupera
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - M Coll
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - E Solà
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - R Barreto
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - E García
- Data Management Centre, EASL-CLIF Consortium, Barcelona, Spain
| | - R Moreira
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - C Elia
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - M Morales-Ruiz
- University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain; Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - M Llopis
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - P Huelin
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - C Solé
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - N Fabrellas
- University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - E Weiss
- Inserm, U1149, Centre de Recherche sur l'Inflammation (CRI), Clichy and Paris, France; UMRS1149, Université Paris Diderot, Paris, France; Département Hospitalo-Universitaire (DHU) UNITY, Service d'Hépatologie, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France; Laboratoire d'Excellence Inflamex, ComUE Sorbonne Paris Cité, Paris, France
| | - F Nevens
- Division of Liver and Biliopancreatic Disorders, University Hospitals of Leuven, KU Leuven, University of Leuven, Belgium
| | - A Gerbes
- Liver Center Munich, Department of Internal Medicine II, University Hospital LMU Munich, Grosshadern, Munich, Germany
| | - J Trebicka
- Department of Internal Medicine I, University of Bonn, Bonn, Germany
| | - F Saliba
- Hôpital Paul Brousse, Villejuif, France
| | - C Fondevila
- University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain; Hepatobiliary Surgery & Liver Transplant, Hospital Clínic de Barcelona, Barcelona, Spain
| | - V Hernández-Gea
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain; Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain
| | - J Fernández
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - M Bernardi
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - V Arroyo
- EASL-CLIF Consortium, Barcelona, Spain
| | - W Jiménez
- University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain; Biochemistry and Molecular Genetics Department, Hospital Clínic de Barcelona, Barcelona, Spain
| | - C Deulofeu
- Data Management Centre, EASL-CLIF Consortium, Barcelona, Spain
| | - M Pavesi
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain; Data Management Centre, EASL-CLIF Consortium, Barcelona, Spain
| | - P Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Surgery, University of Padova, Padova, Italy
| | - R Jalan
- Liver Failure Group, University College London Institute for Liver and Digestive Health, University College London Medical School, Royal Free Hospital, London, United Kingdom
| | - R Moreau
- Inserm, U1149, Centre de Recherche sur l'Inflammation (CRI), Clichy and Paris, France; UMRS1149, Université Paris Diderot, Paris, France; Département Hospitalo-Universitaire (DHU) UNITY, Service d'Hépatologie, Hôpital Beaujon, Assistance Publique des Hôpitaux de Paris, Clichy, France; Laboratoire d'Excellence Inflamex, ComUE Sorbonne Paris Cité, Paris, France
| | - P Sancho-Bru
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - P Ginès
- Liver Unit, Hospital Clínic de Barcelona, University of Barcelona, Barcelona, Spain; University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain.
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30
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Andrassy J, Wolf S, Hoffmann V, Rentsch M, Stangl M, Thomas M, Pratschke S, Frey L, Gerbes A, Meiser B, Angele M, Werner J, Guba M. Rescue management of early complications after liver transplantation-key for the long-term success. Langenbecks Arch Surg 2016; 401:389-96. [PMID: 26960592 DOI: 10.1007/s00423-016-1398-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2015] [Accepted: 03/01/2016] [Indexed: 11/30/2022]
Abstract
PURPOSE Postoperative complications may have not only immediate but also long-term effects on the outcomes. Here, we analyzed the effect of postoperative complications requiring a reoperation (grade 3b) within the first 30 days on patients' and graft survival following liver transplantation. METHODS Graft and patient survival in relation to donor and recipient variables and the need of reoperation for complications of 277 consecutive liver transplants performed from January 2007 to December 2012 were analyzed. RESULTS Two hundred seventy-seven liver transplants were performed in 252 patients. Overall patient and graft survival at 1, 2, and 3 years were significantly reduced in patients requiring a reoperation. The labMELD score was significantly elevated (p = 0.04) and cold ischemia time was prolonged (p = 0.03) in recipients undergoing reoperations. Kaplan-Meier curves indicate that complications impact the outcome primarily within the first 3 months after transplantation. In multivariate analyses, the actual need of reoperation (p < 0.001), the labMELD score (p = 0.05), cold ischemia time (p = 0.02), and the need for hemodialysis pre-transplant (p = 0.05) were the only variables which correlated with the overall survival. CONCLUSION Postoperative complications resulting in reoperations have a significant impact on the outcome primarily in the early phase after liver transplantation. Successful management of postoperative complications is key to every successful liver transplant program.
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Affiliation(s)
- Joachim Andrassy
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany.
| | - Sebastian Wolf
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Verena Hoffmann
- Institute of Medical Information Sciences, Biometry and Epidemiology (IBE), Ludwig Maximilian University, Munich, Germany
| | - Markus Rentsch
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Manfred Stangl
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Michael Thomas
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Sebastian Pratschke
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Lorenz Frey
- Department of Anesthesiology, Ludwig Maximilian University, Munich, Germany
| | - Alexander Gerbes
- Department of Medicine, MED II, Ludwig Maximilian University, Munich, Germany
| | - Bruno Meiser
- Transplant Center, Ludwig Maximilian University, Munich, Germany
| | - Martin Angele
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Jens Werner
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
| | - Markus Guba
- Department of General, Visceral, and Transplant Surgery, Ludwig Maximilian University, Munich, Germany
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31
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Angeli P, Rodríguez E, Piano S, Ariza X, Morando F, Solà E, Romano A, García E, Pavesi M, Risso A, Gerbes A, Willars C, Bernardi M, Arroyo V, Ginès P. Acute kidney injury and acute-on-chronic liver failure classifications in prognosis assessment of patients with acute decompensation of cirrhosis. Gut 2015; 64:1616-22. [PMID: 25311034 DOI: 10.1136/gutjnl-2014-307526] [Citation(s) in RCA: 69] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2014] [Accepted: 09/18/2014] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Prognostic stratification of patients with cirrhosis is common clinical practice. This study compares the prognostic accuracy (28-day and 90-day transplant-free mortality) of the acute-on-chronic liver failure (ACLF) classification (no ACLF, ACLF grades 1, 2 and 3) with that of acute kidney injury (AKI) classification (no AKI, AKI stages 1, 2 and 3). DESIGN The study was performed in 510 patients with an acute decompensation of cirrhosis previously included in the European Association for the Study of the Liver-Chronic Liver Failure consortium CANONIC study. ACLF was evaluated at enrollment and 48 h after enrollment, and AKI was evaluated at 48 h according to Acute Kidney Injury Network criteria. RESULTS 240 patients (47.1%) met the criteria of ACLF at enrollment, while 98 patients (19.2%) developed AKI. The presence of ACLF and AKI was strongly associated with mortality. 28-day transplant-free mortality and 90-day transplant-free mortality of patients with ACLF (32% and 49.8%, respectively) were significantly higher with respect to those of patients without ACLF (6.2% and 16.4%, respectively; both p<0.001). Corresponding values in patients with and without AKI were 46% and 59%, and 12% and 25.6%, respectively (p<0.0001 for both). ACLF classification was more accurate than AKI classification in predicting 90-day mortality (area under the receiving operating characteristic curve=0.72 vs 0.62; p<0.0001) in the whole series of patients. Moreover, assessment of ACLF classification at 48 h had significantly better prognostic accuracy compared with that of both AKI classification and ACLF classification at enrollment. CONCLUSIONS ACLF stratification is more accurate than AKI stratification in the prediction of short-term mortality in patients with acute decompensation of cirrhosis.
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Affiliation(s)
- Paolo Angeli
- Department of Medicine (DIMED), University of Padova, Italy Unit of Hepatic Emergencies and Liver Transplantation, Padova, Italy
| | - Ezequiel Rodríguez
- Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Spain Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain Fundación Renal Iñigo Alvarez de Toledo, (FRIAT), Madrid, Spain
| | - Salvatore Piano
- Department of Medicine (DIMED), University of Padova, Italy Unit of Hepatic Emergencies and Liver Transplantation, Padova, Italy
| | - Xavier Ariza
- Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Spain Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain Fundación Renal Iñigo Alvarez de Toledo, (FRIAT), Madrid, Spain
| | - Filippo Morando
- Department of Medicine (DIMED), University of Padova, Italy Unit of Hepatic Emergencies and Liver Transplantation, Padova, Italy
| | - Elsa Solà
- Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Spain Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain Fundación Renal Iñigo Alvarez de Toledo, (FRIAT), Madrid, Spain Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Spain
| | - Antonietta Romano
- Department of Medicine (DIMED), University of Padova, Italy Unit of Hepatic Emergencies and Liver Transplantation, Padova, Italy
| | | | - Marco Pavesi
- Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Spain Data Management Centre, CLIF Consortium, Barcelona, Spain
| | - Alessandro Risso
- Hospital San Giovanni Battista Hospital, University of Torino, Italy
| | - Alexander Gerbes
- Liver Unit, Klinikum Munich, Lugwig Maximilian University of Munich, Germany
| | - Chris Willars
- Intensive Care Unit, Hepatology Department, Kings College London, UK
| | - Mauro Bernardi
- Semeiotica Medica-Policlinico S. Orsola-Malpighi, University of Bologna, Italy
| | - Vicente Arroyo
- Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Spain Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Spain
| | - Pere Ginès
- Liver Unit, Hospital Clinic de Barcelona, University of Barcelona, Spain Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain Fundación Renal Iñigo Alvarez de Toledo, (FRIAT), Madrid, Spain Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Spain
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32
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Gustot T, Fernandez J, Garcia E, Morando F, Caraceni P, Alessandria C, Laleman W, Trebicka J, Elkrief L, Hopf C, Solís-Munoz P, Saliba F, Zeuzem S, Albillos A, Benten D, Montero-Alvarez JL, Chivas MT, Concepción M, Córdoba J, McCormick A, Stauber R, Vogel W, de Gottardi A, Welzel TM, Domenicali M, Risso A, Wendon J, Deulofeu C, Angeli P, Durand F, Pavesi M, Gerbes A, Jalan R, Moreau R, Ginés P, Bernardi M, Arroyo V, Bañares R, Bocci M, Catalina MV, Chin JL, Coenraad MJ, Coilly A, Dorn L, Gatta A, Gerber L, Grøenbæk H, Graupera I, Guevara M, Hausen A, Karlsen S, Lohse AW, Maggioli C, Markwardt D, Martinez J, Marzano A, de la Mata García M, Mesonero F, Mookerjee RP, Moreno C, Morrell B, Mortensen C, Nevens F, Peck‐Radosavljevic M, Rizzetto M, Romano A, Samuel D, Sauerbruch T, Simon‐Talero M, Solà E, Soriano G, Sperl J, Spindelboeck W, Steib C, Valla D, Verbeke L, Van Vlierberghe H, Wege H, Willars C, Baenas MY, Zaccherini G. Clinical Course of acute-on-chronic liver failure syndrome and effects on prognosis. Hepatology 2015; 62:243-52. [PMID: 25877702 DOI: 10.1002/hep.27849] [Citation(s) in RCA: 407] [Impact Index Per Article: 45.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2014] [Accepted: 04/07/2015] [Indexed: 12/20/2022]
Abstract
UNLABELLED Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation (AD) of cirrhosis, organ failure(s), and high 28-day mortality. We investigated whether assessments of patients at specific time points predicted their need for liver transplantation (LT) or the potential futility of their care. We assessed clinical courses of 388 patients who had ACLF at enrollment, from February through September 2011, or during early (28-day) follow-up of the prospective multicenter European Chronic Liver Failure (CLIF) ACLF in Cirrhosis study. We assessed ACLF grades at different time points to define disease resolution, improvement, worsening, or steady or fluctuating course. ACLF resolved or improved in 49.2%, had a steady or fluctuating course in 30.4%, and worsened in 20.4%. The 28-day transplant-free mortality was low-to-moderate (6%-18%) in patients with nonsevere early course (final no ACLF or ACLF-1) and high-to-very high (42%-92%) in those with severe early course (final ACLF-2 or -3) independently of initial grades. Independent predictors of course severity were CLIF Consortium ACLF score (CLIF-C ACLFs) and presence of liver failure (total bilirubin ≥12 mg/dL) at ACLF diagnosis. Eighty-one percent had their final ACLF grade at 1 week, resulting in accurate prediction of short- (28-day) and mid-term (90-day) mortality by ACLF grade at 3-7 days. Among patients that underwent early LT, 75% survived for at least 1 year. Among patients with ≥4 organ failures, or CLIF-C ACLFs >64 at days 3-7 days, and did not undergo LT, mortality was 100% by 28 days. CONCLUSIONS Assessment of ACLF patients at 3-7 days of the syndrome provides a tool to define the emergency of LT and a rational basis for intensive care discontinuation owing to futility.
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Affiliation(s)
- Thierry Gustot
- Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| | | | - Elisabet Garcia
- Data Management Center of the EASL-CLIF Consortium, CIBEReHD, Barcelona, Spain
| | | | | | | | - Wim Laleman
- University Hospital Gasthuisberg, Leuven, Belgium
| | | | | | - Corinna Hopf
- University of Munich, Klinikum der LMU, Munich, Germany
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | - Carme Deulofeu
- Data Management Center of the EASL-CLIF Consortium, CIBEReHD, Barcelona, Spain
| | | | | | - Marco Pavesi
- Data Management Center of the EASL-CLIF Consortium, CIBEReHD, Barcelona, Spain
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33
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Angeli P, Gines P, Wong F, Bernardi M, Boyer TD, Gerbes A, Moreau R, Jalan R, Sarin SK, Piano S, Moore K, Lee SS, Durand F, Salerno F, Caraceni P, Kim WR, Arroyo V, Garcia-Tsao G. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. Gut 2015; 64:531-7. [PMID: 25631669 DOI: 10.1136/gutjnl-2014-308874] [Citation(s) in RCA: 320] [Impact Index Per Article: 35.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Pere Gines
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain Instituto Reina Sofia d'Investigación en Nefrologia (IRSIN), Barcelona, Spain
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Mauro Bernardi
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Thomas D Boyer
- Department of Medicine, Liver Research Institute, University of Arizona, College of Medicine, Tucson, Arizona, USA
| | - Alexander Gerbes
- Liver Unit, Klinikum Munich, Ludwig Maximilian University of Munich, Munich, Germany
| | - Richard Moreau
- Inserm U1149, Centre de recherche sur l'Inflammation (CRI), Paris, France UMR S_1149, Université Paris Diderot, Paris, France DHU UNITY, Service d'hépatologie, Hôpital Beaujon, APHP, Clichy, France
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Salvatore Piano
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Kevin Moore
- UCL Institute of Liver and Digestive Health, Royal Free Campus, University College London, London, UK
| | - Samuel S Lee
- Liver Unit, University of Calgary, Calgary, Canada
| | - Francois Durand
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France INSERM U773, Centre de Recherche Biomédicale Bichat Beaujon CRB3, Clichy, France
| | - Francesco Salerno
- Policlinico IRCCS San Donato, Medicina Interna ed Epatologia, Università di Milano, Milan, Italy
| | - Paolo Caraceni
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University Medical School, Palo Alto, California, USA
| | - Vicente Arroyo
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
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Angeli P, Ginès P, Wong F, Bernardi M, Boyer TD, Gerbes A, Moreau R, Jalan R, Sarin SK, Piano S, Moore K, Lee SS, Durand F, Salerno F, Caraceni P, Kim WR, Arroyo V, Garcia-Tsao G. Diagnosis and management of acute kidney injury in patients with cirrhosis: revised consensus recommendations of the International Club of Ascites. J Hepatol 2015; 62:968-74. [PMID: 25638527 DOI: 10.1016/j.jhep.2014.12.029] [Citation(s) in RCA: 452] [Impact Index Per Article: 50.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/17/2014] [Accepted: 12/17/2014] [Indexed: 02/08/2023]
Affiliation(s)
- Paolo Angeli
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine-DIMED, University of Padova, Padova, Italy.
| | - Pere Ginès
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain; Instituto Reina Sofia d'Investigación en Nefrologia (IRSIN), Barcelona, Spain
| | - Florence Wong
- Division of Gastroenterology, Department of Medicine, University of Toronto, Toronto, Canada
| | - Mauro Bernardi
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - Thomas D Boyer
- Department of Medicine, Liver Research Institute, University of Arizona, College of Medicine, Tucson, Arizona, USA
| | - Alexander Gerbes
- Liver Unit, Klinikum Munich, Ludwig Maximilian University of Munich, Munich, Germany
| | - Richard Moreau
- Inserm U1149, Centre de recherche sur l'Inflammation (CRI), Paris, France; UMR S_1149, Université Paris Diderot, Paris, France; DHU UNITY, Service d'hépatologie, Hôpital Beaujon, APHP, Clichy, France
| | - Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Salvatore Piano
- Unit of Hepatic Emergencies and Liver Transplantation, Department of Medicine-DIMED, University of Padova, Padova, Italy
| | - Kevin Moore
- UCL Institute of Liver and Digestive Health, Royal Free Campus, University College London, London, UK
| | - Samuel S Lee
- Liver Unit, University of Calgary, Calgary, Canada
| | - Francois Durand
- Hepatology and Liver Intensive Care Unit, Hospital Beaujon, Clichy, France; INSERM U773, Centre de Recherche Biomédicale Bichat Beaujon CRB3, Clichy, France
| | - Francesco Salerno
- Policlinico IRCCS San Donato, Medicina Interna ed Epatologia, Università di Milano, Milan, Italy
| | - Paolo Caraceni
- Dipartimento di Scienze Mediche e Chirurgiche, Alma Mater Studiorum, University of Bologna, Bologna, Italy
| | - W Ray Kim
- Division of Gastroenterology and Hepatology, Stanford University Medical School, Palo Alto, California, USA
| | - Vicente Arroyo
- Liver Unit, Hospital Clinic, University of Barcelona, Barcelona, Spain; Institut d'Investigacions Biomediques Agust Pi i Sunyer (IDIBAPS), Barcelona, Spain; Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Barcelona, Spain
| | - Guadalupe Garcia-Tsao
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, Connecticut, USA
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Jalan R, Saliba F, Pavesi M, Amoros A, Moreau R, Ginès P, Levesque E, Durand F, Angeli P, Caraceni P, Hopf C, Alessandria C, Rodriguez E, Solis-Muñoz P, Laleman W, Trebicka J, Zeuzem S, Gustot T, Mookerjee R, Elkrief L, Soriano G, Cordoba J, Morando F, Gerbes A, Agarwal B, Samuel D, Bernardi M, Arroyo V. Development and validation of a prognostic score to predict mortality in patients with acute-on-chronic liver failure. J Hepatol 2014; 61:1038-47. [PMID: 24950482 DOI: 10.1016/j.jhep.2014.06.012] [Citation(s) in RCA: 624] [Impact Index Per Article: 62.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2014] [Revised: 06/02/2014] [Accepted: 06/11/2014] [Indexed: 02/06/2023]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is a frequent syndrome (30% prevalence), characterized by acute decompensation of cirrhosis, organ failure(s) and high short-term mortality. This study develops and validates a specific prognostic score for ACLF patients. METHODS Data from 1349 patients included in the CANONIC study were used. First, a simplified organ function scoring system (CLIF Consortium Organ Failure score, CLIF-C OFs) was developed to diagnose ACLF using data from all patients. Subsequently, in 275 patients with ACLF, CLIF-C OFs and two other independent predictors of mortality (age and white blood cell count) were combined to develop a specific prognostic score for ACLF (CLIF Consortium ACLF score [CLIF-C ACLFs]). A concordance index (C-index) was used to compare the discrimination abilities of CLIF-C ACLF, MELD, MELD-sodium (MELD-Na), and Child-Pugh (CPs) scores. The CLIF-C ACLFs was validated in an external cohort and assessed for sequential use. RESULTS The CLIF-C ACLFs showed a significantly higher predictive accuracy than MELDs, MELD-Nas, and CPs, reducing (19-28%) the corresponding prediction error rates at all main time points after ACLF diagnosis (28, 90, 180, and 365 days) in both the CANONIC and the external validation cohort. CLIF-C ACLFs computed at 48 h, 3-7 days, and 8-15 days after ACLF diagnosis predicted the 28-day mortality significantly better than at diagnosis. CONCLUSIONS The CLIF-C ACLFs at ACLF diagnosis is superior to the MELDs and MELD-Nas in predicting mortality. The CLIF-C ACLFs is a clinically relevant, validated scoring system that can be used sequentially to stratify the risk of mortality in ACLF patients.
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Affiliation(s)
- Rajiv Jalan
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, United Kingdom
| | - Faouzi Saliba
- Hôpital Paul Brousse, Villejuif, France; Unité INSERM U785, Paris, France
| | - Marco Pavesi
- Data Management Centre of the EASL CLIF Consortium, Barcelona, Spain
| | - Alex Amoros
- Data Management Centre of the EASL CLIF Consortium, Barcelona, Spain
| | - Richard Moreau
- INSERM U773 and Service d'Hépatologie, Hôpital Beaujon, Clichy, France
| | | | - Eric Levesque
- Hôpital Paul Brousse, Villejuif, France; Unité INSERM U785, Paris, France
| | - Francois Durand
- INSERM U773 and Service d'Hépatologie, Hôpital Beaujon, Clichy, France
| | | | | | - Corinna Hopf
- Ludwig Maximilian University Munich, Klinikum der Universität München, Germany
| | | | | | | | - Wim Laleman
- University Hospital Gasthuisberg, Leuven, Belgium
| | | | | | | | - Rajeshwar Mookerjee
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, United Kingdom
| | - Laure Elkrief
- INSERM U773 and Service d'Hépatologie, Hôpital Beaujon, Clichy, France
| | | | | | | | - Alexander Gerbes
- Ludwig Maximilian University Munich, Klinikum der Universität München, Germany
| | - Banwari Agarwal
- Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, United Kingdom
| | - Didier Samuel
- Hôpital Paul Brousse, Villejuif, France; Unité INSERM U785, Paris, France
| | - Mauro Bernardi
- Policlinico St Orsola Malpighi, Bologna, Italy; EASL-CLIF Consortium
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36
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Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, Durand F, Gustot T, Saliba F, Domenicali M, Gerbes A, Wendon J, Alessandria C, Laleman W, Zeuzem S, Trebicka J, Bernardi M, Arroyo V. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013; 144:1426-37, 1437.e1-9. [PMID: 23474284 DOI: 10.1053/j.gastro.2013.02.042] [Citation(s) in RCA: 1866] [Impact Index Per Article: 169.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2012] [Revised: 02/17/2013] [Accepted: 02/20/2013] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Patients with cirrhosis hospitalized for an acute decompensation (AD) and organ failure are at risk for imminent death and considered to have acute-on-chronic liver failure (ACLF). However, there are no established diagnostic criteria for ACLF, so little is known about its development and progression. We aimed to identify diagnostic criteria of ACLF and describe the development of this syndrome in European patients with AD. METHODS We collected data from 1343 hospitalized patients with cirrhosis and AD from February to September 2011 at 29 liver units in 8 European countries. We used the organ failure and mortality data to define ACLF grades, assess mortality, and identify differences between ACLF and AD. We established diagnostic criteria for ACLF based on analyses of patients with organ failure (defined by the chronic liver failure-sequential organ failure assessment [CLIF-SOFA] score) and high 28-day mortality rate (>15%). RESULTS Of the patients assessed, 303 had ACLF when the study began, 112 developed ACLF, and 928 did not have ACLF. The 28-day mortality rate among patients who had ACLF when the study began was 33.9%, among those who developed ACLF was 29.7%, and among those who did not have ACLF was 1.9%. Patients with ACLF were younger and more frequently alcoholic, had more associated bacterial infections, and had higher numbers of leukocytes and higher plasma levels of C-reactive protein than patients without ACLF (P < .001). Higher CLIF-SOFA scores and leukocyte counts were independent predictors of mortality in patients with ACLF. In patients without a prior history of AD, ACLF was unexpectedly characterized by higher numbers of organ failures, leukocyte count, and mortality compared with ACLF in patients with a prior history of AD. CONCLUSIONS We analyzed data from patients with cirrhosis and AD to establish diagnostic criteria for ACLF and showed that it is distinct from AD, based not only on the presence of organ failure(s) and high mortality rate but also on age, precipitating events, and systemic inflammation. ACLF mortality is associated with loss of organ function and high leukocyte counts. ACLF is especially severe in patients with no prior history of AD.
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Affiliation(s)
- Richard Moreau
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
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37
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Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, Durand F, Gustot T, Saliba F, Domenicali M, Gerbes A, Wendon J, Alessandria C, Laleman W, Zeuzem S, Trebicka J, Bernardi M, Arroyo V. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013. [PMID: 23474284 DOI: 10.1053/j.gastro.2013.02.042]available] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS Patients with cirrhosis hospitalized for an acute decompensation (AD) and organ failure are at risk for imminent death and considered to have acute-on-chronic liver failure (ACLF). However, there are no established diagnostic criteria for ACLF, so little is known about its development and progression. We aimed to identify diagnostic criteria of ACLF and describe the development of this syndrome in European patients with AD. METHODS We collected data from 1343 hospitalized patients with cirrhosis and AD from February to September 2011 at 29 liver units in 8 European countries. We used the organ failure and mortality data to define ACLF grades, assess mortality, and identify differences between ACLF and AD. We established diagnostic criteria for ACLF based on analyses of patients with organ failure (defined by the chronic liver failure-sequential organ failure assessment [CLIF-SOFA] score) and high 28-day mortality rate (>15%). RESULTS Of the patients assessed, 303 had ACLF when the study began, 112 developed ACLF, and 928 did not have ACLF. The 28-day mortality rate among patients who had ACLF when the study began was 33.9%, among those who developed ACLF was 29.7%, and among those who did not have ACLF was 1.9%. Patients with ACLF were younger and more frequently alcoholic, had more associated bacterial infections, and had higher numbers of leukocytes and higher plasma levels of C-reactive protein than patients without ACLF (P < .001). Higher CLIF-SOFA scores and leukocyte counts were independent predictors of mortality in patients with ACLF. In patients without a prior history of AD, ACLF was unexpectedly characterized by higher numbers of organ failures, leukocyte count, and mortality compared with ACLF in patients with a prior history of AD. CONCLUSIONS We analyzed data from patients with cirrhosis and AD to establish diagnostic criteria for ACLF and showed that it is distinct from AD, based not only on the presence of organ failure(s) and high mortality rate but also on age, precipitating events, and systemic inflammation. ACLF mortality is associated with loss of organ function and high leukocyte counts. ACLF is especially severe in patients with no prior history of AD.
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Affiliation(s)
- Richard Moreau
- Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France
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38
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Affiliation(s)
- R Wiest
- Department for visceral surgery and medicine, University Hospital Bern, Switzerland.
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39
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Wong F, Watson H, Gerbes A, Vilstrup H, Badalamenti S, Bernardi M, Ginès P. Satavaptan for the management of ascites in cirrhosis: efficacy and safety across the spectrum of ascites severity. Gut 2012; 61:108-16. [PMID: 21836029 DOI: 10.1136/gutjnl-2011-300157] [Citation(s) in RCA: 99] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE Satavaptan, a vasopressin V2 receptor antagonist, has been shown to improve the control of ascites in cirrhosis in short-term phase II studies. The aim of this study was to evaluate the efficacy and safety of satavaptan in three different populations of patients with cirrhosis and ascites. METHODS 1200 patients were included in three randomised double-blind studies comparing satavaptan with placebo in uncomplicated ascites (study 1: n=463 patients) and difficult-to-treat ascites, with and without concomitant diuretic treatment (studies 2 and 3: n=497 and n=240 patients, respectively). RESULTS Satavaptan was not more effective than placebo in the control of ascites in any of the populations studied as estimated by the primary efficacy endpoints: worsening of ascites (study 1) and the cumulative number of large-volume paracenteses during 12 weeks (studies 2 and 3). Nevertheless, some of the secondary efficacy endpoints related to the treatment of ascites were met in the three studies, suggesting a slight advantage of satavaptan over placebo in delaying ascites formation. Moreover, satavaptan was more effective than placebo in improving the serum sodium concentration in patients with hyponatraemia. The incidence of major complications of cirrhosis during follow-up did not differ significantly between the satavaptan and placebo groups in the three studies. Overall, the rate of any treatment-related adverse events, serious treatment-related events and treatment-related events leading to permanent discontinuation of treatment did not differ significantly between the treatment groups. However, in study 2 mortality was higher in patients treated with satavaptan compared with placebo (HR 1.47; 95% CI 1.01 to 2.15); no significant differences in mortality between the two groups were observed in the other two studies. No specific cause for the increased mortality was identified. Most deaths were associated with known complications of liver cirrhosis. CONCLUSION Satavaptan, alone or in combination with diuretics, is not clinically beneficial in the long-term management of ascites in cirrhosis.
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Affiliation(s)
- Florence Wong
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario, Canada
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40
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Wong F, Nadim MK, Kellum JA, Salerno F, Bellomo R, Gerbes A, Angeli P, Moreau R, Davenport A, Jalan R, Ronco C, Genyk Y, Arroyo V. Working Party proposal for a revised classification system of renal dysfunction in patients with cirrhosis. Gut 2011; 60:702-9. [PMID: 21325171 DOI: 10.1136/gut.2010.236133] [Citation(s) in RCA: 272] [Impact Index Per Article: 20.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES To propose an improvement on the current classification of renal dysfunction in cirrhosis. Clinicians caring for patients with cirrhosis recognize that the development of renal dysfunction is associated with significant morbidity and mortality. While most cases of renal dysfunction in cirrhosis are functional in nature, developed as a result of changes in haemodynamics, cardiac function, and renal auto-regulation, there is an increasing number of patients with cirrhosis and structural changes in their kidney as a cause of renal dysfunction. Therefore, there is a need for a newer classification to include both functional and structural renal diseases. DESIGN A working party consisting of specialists from multiple disciplines conducted literature search and developed summary statements, incorporating the renal dysfunction classification used in nephrology. These were discussed and revised to produce this proposal. SETTING Multi-disciplinary international meeting. PATIENTS None. INTERVENTIONS Literature search using keywords of cirrhosis, renal dysfunction, acute kidney injury (AKI), chronic kidney injury (CKD), and hepatorenal syndrome. RESULTS Acute kidney injury will include all causes of acute deterioration of renal function as indicated by an increase in serum creatinine of >50% from baseline, or a rise in serum creatinine of ≥ 26.4 µmol/L (≥ 0.3 mg/dL) in < 48 hours. Chronic renal disease will be defined as an estimated glomerular filtration rate (GFR) of < 60 ml/min calculated using the Modification of Diet in Renal Disease 6 (MDRD6) formula, recognising that the MDRD6 formula is not perfect for the cirrhotic patients and this may change as improved means of estimating GFR becomes available. Acute on chronic kidney disease will be defined as AKI superimposed on existing chronic renal disease using the above definitions for AKI and CKD. CONCLUSIONS Accepting this new classification will allow studies into the epidemiology, incidence, prevalence, natural history and the development of new treatments for these subtypes of renal dysfunction in cirrhosis.
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Affiliation(s)
- Florence Wong
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario M5G2C4, Canada.
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41
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Wong F, Nadim MK, Kellum JA, Salerno F, Bellomo R, Gerbes A, Angeli P, Moreau R, Davenport A, Jalan R, Ronco C, Genyk Y, Arroyo V. Working Party proposal for a revised classification system of renal dysfunction in patients with cirrhosis. Gut 2011. [PMID: 21325171 DOI: 10.1136/gut.2010.23613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES To propose an improvement on the current classification of renal dysfunction in cirrhosis. Clinicians caring for patients with cirrhosis recognize that the development of renal dysfunction is associated with significant morbidity and mortality. While most cases of renal dysfunction in cirrhosis are functional in nature, developed as a result of changes in haemodynamics, cardiac function, and renal auto-regulation, there is an increasing number of patients with cirrhosis and structural changes in their kidney as a cause of renal dysfunction. Therefore, there is a need for a newer classification to include both functional and structural renal diseases. DESIGN A working party consisting of specialists from multiple disciplines conducted literature search and developed summary statements, incorporating the renal dysfunction classification used in nephrology. These were discussed and revised to produce this proposal. SETTING Multi-disciplinary international meeting. PATIENTS None. INTERVENTIONS Literature search using keywords of cirrhosis, renal dysfunction, acute kidney injury (AKI), chronic kidney injury (CKD), and hepatorenal syndrome. RESULTS Acute kidney injury will include all causes of acute deterioration of renal function as indicated by an increase in serum creatinine of >50% from baseline, or a rise in serum creatinine of ≥ 26.4 µmol/L (≥ 0.3 mg/dL) in < 48 hours. Chronic renal disease will be defined as an estimated glomerular filtration rate (GFR) of < 60 ml/min calculated using the Modification of Diet in Renal Disease 6 (MDRD6) formula, recognising that the MDRD6 formula is not perfect for the cirrhotic patients and this may change as improved means of estimating GFR becomes available. Acute on chronic kidney disease will be defined as AKI superimposed on existing chronic renal disease using the above definitions for AKI and CKD. CONCLUSIONS Accepting this new classification will allow studies into the epidemiology, incidence, prevalence, natural history and the development of new treatments for these subtypes of renal dysfunction in cirrhosis.
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Affiliation(s)
- Florence Wong
- Department of Medicine, Toronto General Hospital, University of Toronto, Toronto, Ontario M5G2C4, Canada.
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Zaruba MM, Waggershauser T, Weckbach S, Gerbes A, Mühling O, Kääb S. [64-year old patient with tachycardia and signs of heart failure]. Internist (Berl) 2008; 50:489-92. [PMID: 19099274 DOI: 10.1007/s00108-008-2260-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
We report on a 64-year old patient with known Morbus Osler and high cardiac output failure due to distinct arterio-venous malformations of the liver. Since the patient suffered from severe right heart insufficiency despite optimized medical therapy, we decided to conduct an interventional occlusion of the hepatic shunts in three single sessions. The transient elevation of transaminases was reversible. After interventional therapy cardiac output decreased from 20 l/min to 15 l/min (25%) leading to a reduction of diuretic dosage and a sustained stabilization of the clinical condition.
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Affiliation(s)
- M M Zaruba
- Medizinische Klinik I, Klinikum Grosshadern, Ludwig-Maximilians-Universität, Marchioninistrasse 15, Munich, Germany.
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Löhe F, Angele MK, Rentsch M, Graeb C, Gerbes A, Löhrs U, Beuers U, Jauch KW. Multifocal manifestation does not affect vascular invasion of hepatocellular carcinoma: implications for patient selection in liver transplantation. Clin Transplant 2008; 21:696-701. [PMID: 17988261 DOI: 10.1111/j.1399-0012.2007.00707.x] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
BACKGROUND AND AIMS Liver transplantation (OLT) for hepatocellular carcinoma (HCC) improves patient survival when tumor size and number are limited according to the Milan criteria. However, the impact of tumor size vs. the number of lesions for tumor recurrence after OLT is unclear. Microvascular invasion appears to be a significant risk factor for tumor recurrence. Therefore, it was the aim of this study to investigate tumor differentiation and microvascular invasion in relation to tumor number and size and their impact on survival after transplantation. PATIENTS AND METHODS In 97 adult HCC patients who underwent OLT between June 1985 and December 2005 the incidence of microvascular invasion, tumor differentiation, and the number and size of tumor lesions were analyzed retrospectively. Their impact on survival was studied by multivariate analysis. RESULTS Microvascular invasion was the only independent negative predictor of survival after OLT for HCC (p = 0.025). Tumor size > 5 cm was predictive for microvascular invasion (p = 0.007). In contrast, tumor number did not affect the incidence of microvascular invasion or cumulative survival. CONCLUSION The size of the largest HCC lesion, but not the number of tumors, determined microvascular invasion, a predictor of the outcome following OLT for HCC. Thus, the number of HCC lesions should not be applied to patient selection prior to OLT. These data support the extension of the Milan criteria for the selection of HCC patients for OLT with regard to tumor number, but not tumor size.
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Affiliation(s)
- Florian Löhe
- Department of Surgery, Ludwig-Maximilians-University Munich, Klinikum Grosshadern, Munich, Germany.
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Abstract
Abstract
Hepatorenal syndrome (HRS) is a serious complication of end-stage liver disease, occurring mainly in patients with advanced cirrhosis and ascites, who have marked circulatory dysfunction,1 as well as in patients with acute liver failure.2 In spite of its functional nature, HRS is associated with a poor prognosis,3 4 and the only effective treatment is liver transplantation.
During the 56th Meeting of the American Association for the Study of Liver Diseases, the International Ascites Club held a Focused Study Group (FSG) on HRS for the purpose of reporting the results of an international workshop and to reach a consensus on a new definition, criteria for diagnosis and recommendations on HRS treatment. A similar workshop was held in Chicago in 1994 in which standardised nomenclature and diagnostic criteria for refractory ascites and HRS were established.5 The introduction of innovative treatments and improvements in our understanding of the pathogenesis of HRS during the previous decade led to an increasing need to undertake a new consensus meeting. This paper reports the scientific rationale behind the new definitions and recommendations.
The international workshop included four issues debated by four panels of experts (see Acknowledgements). The issues were: (1) evidence-based HRS pathogenesis; (2) treatment of HRS using vasoconstrictors; (3) other HRS treatments using transjugular intrahepatic portosystemic stent-shunt (TIPS) and extracorporeal albumin dialysis (ECAD); and (4) new definitions and diagnostic criteria for HRS and recommendations for its treatment.
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Affiliation(s)
- Francesco Salerno
- Department of Internal Medicine, Policlinico IRCCS San Donato, University of Milan, Via Morandi, 30, 20097 San Donato (MI), Italy.
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Stangl MJ, Beuers U, Schauer R, Lang T, Gerbes A, Briegel J, Da Silva L, Schildberg FW, Rau HG. [Allogenic liver transplantation: a form of "gene therapy" in metabolic diseases. Munich results and a review]. Chirurg 2000; 71:808-19. [PMID: 10986603 DOI: 10.1007/s001040051140] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Abstract
INTRODUCTION Liver transplantation is the method of choice for metabolic diseases and end-stage liver failure. METHODS At the Klinikum Grosshadern we have performed liver transplantation for inborn errors of metabolism in 24 patients (5.3% of all transplantations, 16 adults, age 39 +/- 13 years; 8 children, age 9 +/- 3 years); 19 patients received a transplant for end-stage liver disease, and in 5 cases because of fulminant hepatic failure. RESULTS Twenty-four patients received 27 transplants. In 3 cases, a split-liver transplantation was performed; one patient received a combined lung-liver graft. The 5-year survival rate for children is 100% and for adults 68%. CONCLUSIONS Liver transplantation for inborn errors of metabolism not only replaces the diseased organ, but also leads to complete reversal of the metabolic defect.
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Affiliation(s)
- M J Stangl
- Chirurgische Klinik und Poliklinik, Ludwig-Maximilians-Universität, Klinikum Grosshadern, München.
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Sauerbruch T, Kleber G, Gerbes A, Paumgartner G. Prophylaxis of first variceal hemorrhage in patients with liver cirrhosis. Klin Wochenschr 1986; 64:1267-75. [PMID: 2881023 DOI: 10.1007/bf01785707] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
Prophylaxis of bleeding from esophageal varices is a very tempting concept at first glance, especially under the assumption of a high mortality associated with first variceal hemorrhage. Up to now four different measures have been tried for prophylaxis: portacaval shunt operation, devascularization procedures, sclerotherapy, and drugs. With the exception of portacaval shunts, ongoing controlled trials show a weak trend toward reduction of variceal bleeding and prolongation of survival in selected patients with compensated cirrhosis and large varices. However, prophylaxis of first variceal bleeding must still be regarded as experimental and should be restricted to controlled clinical studies.
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