Survival in infection-related acute-on-chronic liver failure is defined by extrahepatic organ failures

Bajaj, Jasmohan S.; O’Leary, Jacqueline G.; Reddy, K. Rajender; Wong, Florence; Biggins, Scott W.; Patton, Heather; Fallon, Michael B.; García–Tsao, Guadalupe; Maliakkal, Benedict; Malik, Raza; Subramanian, Ram; Thacker, Leroy R.; Kamath, Patrick S.

doi:10.1002/hep.27077

Cited by 487 publications

(540 citation statements)

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“…Organ failures and infections were defined per our previous work. (32) At 1 week postdischarge, the research assistant at each study site assessed the patient's KPS using questions directed to the patient and the caregiver in a telephone interview. Per the accepted standard, KPS was categorized into low (score 10-40), intermediate (50-70), and high (80-100).…”

Section: Article Informationmentioning

confidence: 99%

A Karnofsky performance status–based score predicts death after hospital discharge in patients with cirrhosis

et al. 2017

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Identification of patients with cirrhosis at risk for death within 3 months of discharge from the hospital is essential to individualize postdischarge plans. The objective of the study was to identify an easy-to-use prognostic model based on the Karnofsky Performance Status (KPS). The North American Consortium for the Study of End-Stage Liver Disease consists of 16 tertiary-care hepatology centers that prospectively enroll nonelectively admitted cirrhosis patients. Patients enrolled had KPS assessed 1 week postdischarge. KPS was categorized into low (score 10-40), intermediate , and high (80-100). Of 954 middle-aged patients (57 6 10 years, 63% men) with a median Model for End-Stage Liver Disease (MELD) score of 17 (interquartile range 13-21), the mortality rates for the low, intermediate, and high performance status groups were 23% (36/ 159), 11% (55/489), and 5% (15/306), respectively. Low, intermediate, and high performance status was seen in 17%, 51%, and 32% of the cohort, respectively. Low performance status was associated with older age, dialysis, hepatic encephalopathy, longer length of stay, and higher white blood cell count or MELD score at discharge. A model was derived using the three independent predictors of 3-month mortality: KPS, age, and MELD score. This score had better discrimination (area under the receiver operating characteristic curve 5 0.74) than a model using MELD (area under the receiver operating characteristic curve 5 0.62) or MELD and age (area under the receiver operating characteristic curve 5 0.67) to predict 3-month mortality. Conclusions: Cirrhosis patients at risk for 3-month postdischarge mortality can be identified using a novel KPS-based score; this score may be adopted in practice to guide postdischarge early interventions, including the integrated provision of active and palliative management strategies. (HEPATOLOGY 2017;65:217-224).P atients with cirrhosis can experience sudden deteriorations in health that lead to increased morbidity, repeated hospitalizations, and mortality. (1)(2)(3) Hospitalization is a marker for a variety of poor outcomes including readmission and death. Although we are gaining a better understanding of risk factors for readmission in discharged patients, (1,(4)(5)(6) we lack a practical prognostic model to identify those at highest risk for 3-month postdischarge mortality.Identifying this group would facilitate interventions that include more intensive follow-up and consideration of early liver transplant when available. Moreover, an estimation of the probability of survival can help to inform the type of integrated palliative support that is provided to patients.To date, mortality prediction in patients with cirrhosis has been predominated by liver-specific and kidney-specific prognostic indicators such as the Abbreviations: AUC, area under the receiver operating characteristic curve; CI, confidence interval; HE, hepatic encephalopathy; KAM, KPS, age, MELD (model); KPS, Karnofsky Performance Status; MELD, Model for End-Stage Liver Disease; OR, odd...

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Section: Article Informationmentioning

confidence: 99%

A Karnofsky performance status–based score predicts death after hospital discharge in patients with cirrhosis

et al. 2017

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“…Az SBP a kórházi ellátást igénylő cirrhosisos betegek körében a leggyakoribb fertőző megbetegedés. Hospitalizált betegek 25-37%-ában észlelt fertőzések 22-23%-át jelenti [14,15,16,17]. Evans és munkatársainak tanulmányában tünetmentes járóbetegek körében az SBP prevalenciája 1,5-3,5% volt [18].…”

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Spontán bakteriális peritonitis

Velkey

Vitális

2017

Orvosi Hetilap

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A spontán bakteriális peritonitis megjelenésére ascitessel járó májzsugorban szenvedőknél számíthatunk. A kóroko-zók intestinalis bakteriális transzlokáció útján a véráramba jutnak, majd az ascitesbe kerülve elszaporodnak. A betegség diagnózisa az ascites megemelkedett neutrofilszámának igazolásán alapszik (>0,25 G/L). A tenyésztés gyakran álnegatív, az antibiotikum-érzékenység meghatározása miatt mégis fontos. Kezelésére stabil betegekben iv., majd orálisan alkalmazott ciprofloxacint vagy amoxicillin/klavulánsavat ajánlanak, súlyosabb állapotban III. generációs cefalosporint. Nosocomialis infekció esetén a gyakoribb Gram-pozitív és antibiotikum-rezisztens patogének okozta fertőzés miatt imipenemet vagy meropenemet célszerű választani. Profilaxisként norfloxacint javasolnak, bár a fokozódó rezisztenciával számolni kell. Gastrointestinalis vérzés esetén öt napon át alkalmazott norfloxacin, súlyos máj-elégtelenek vérzése esetén ceftriaxon adása indokolt. Tartós antibiotikum-profilaxist (napi 400 mg norfloxacin) -primer prevencióként -alacsony ascitesösszfehérje-szintű, előrehaladott májzsugorosok számára ajánlanak, míg szekunder prevenció gyanánt minden spontán bakteriális peritonitisből felépült beteg számára indokolt adni. Nem mindenki ért egyet a tartós antibiotikum-profilaxissal. A cikk megírásának ösztönzője volt az a mindennapi tapasztalat, hogy a kórképpel kapcsolatos ismeretek nem eléggé állnak a cirrhosis kezelésének középpontjában. Orv. Hetil., 2017, 158(2), 50-57. Kulcsszavak: májzsugor, intestinalis bakteriális transzlokáció, kezelés, profilaxis Spontaneous bacterial peritonitisSpontaneous bacterial peritonitis occurs most commonly in cirrhotic patients with ascites. Pathogens get into the circulation by intestinal translocation and colonize in peritoneal fluid. Diagnosis of spontaneous bacterial peritonitis is based on elevated polymorphonuclear leukocyte count in the ascites (>0,25 G/L). Ascites culture is often negative but aids to get information about antibiotic sensitivity in positive cases. Treatment in stable patient can be intravenous then orally administrated ciprofloxacin or amoxicillin/clavulanic acid, while in severe cases intravenous III. generation cephalosporin. Nosocomial spontaneous bacterial peritonitis often caused by Gram-positive bacteria and multi-resistant pathogens can also be expected thus carbapenem should be the choice of the empiric treatment. Antibiotic prophylaxis should be considered. Norfloxacin is used most commonly, but changes are expected due to increase in quinolone resistance. As a primary prophylaxis, a short-term antibiotic treatment is recommended after gastrointestinal bleeding for 5 days, while long-term prophylaxis is for patients with low ascites protein, and advanced disease (400 mg/day). Secondary prophylaxis is recommended for all patients recovered from spontaneous bacterial peritonitis. Due to increasing antibiotic use of antibiotics prophylaxis is debated to some degree.

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“…There have been attempts to classify the ACLF precipitated by infection as iACLF, which has high 30-day mortality. 28 Infections in cirrhosis have also been described as the fifth clinical stage with fourfold increase in mortality. 42 Infections in this setting may be related to liver disease [e.g.…”

Section: Acute On Chronic Livermentioning

confidence: 99%

“…Majority of papers listed in listed in Table 1 have used arbitrary definitions which are not based on observed data and will not be discussed here. Three main exceptions are the working groups in US, Europe and Asia-Pacific definition, 27,28,30 who have analyzed a large number of patients to come to a consensus definition which is also being revised as and when additional data become available. Here again NAC-SELD (North American Consortium for Study of End Stage Liver Disease) approach is somewhat similar to that of EASL because both believe that poor outcome is best predicted by extra-hepatic organ failure.…”

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confidence: 99%