Identification and prognostic impact of malnutrition in a population screened for liver transplantation.

BACKGROUND & AIMS: Sarcopenia is prevalent in patients with liver cirrhosis and is negatively associated with clinical outcomes. In a population screened for liver transplantation we aimed to assess the prevalence of abnormal nutritional status and to what extent a clinical screening tool is able to reliably select patients for extensive nutritional assessment including CT. We also evaluated which nutritional parameters are independently associated with clinical outcomes. METHODS: Analysis of consecutive patients undergoing detailed nutritional assessment during pre-liver transplantation screening from October 2015 to April 2017. RESULTS: In 102 included patients (66.7% male; median age of 56.3 years (IQR 43.9-64.0); median MELDNa score of 14.7 (IQR 9.4-19.0)), presarcopenia was diagnosed in 30/102 patients (29.4%), sarcopenia in 20/102 (19.6%), and impaired muscle quality in 19/102 (18.6%). Application of the European association for the Study of the Liver rapid screen tool as the primary instrument for nutritional assessment would have resulted in selection of 40/69 cases, thus 42.0% of patients with actual muscle mass depletion and/or impaired muscle function would not have been selected for further nutritional evaluation. In contrast to muscle mass depletion, impaired muscle function was a significant predictor for 6-month decompensation-free (p = 0.006) and hospitalization-free (p = 0.003) survival, when adjusted for age and MELDNa score. CONCLUSIONS: In our population the efficacy of a clinical screening tool for malnutrition was unsatisfactory. A detailed nutritional assessment is therefore recommended in all patients undergoing liver transplantation screening. Impaired muscle function might be clinically more relevant than muscle mass depletion, and muscle function testing should be considered an integral part of nutritional assessment in chronic liver disease.

The efficacy and safety of rifaximin-α: a 2-year observational study of overt hepatic encephalopathy.

BACKGROUND: After 5 years since the registration of rifaximin-α as a secondary prophylaxis for overt hepatic encephalopathy (HE) in the Netherlands, we aimed to evaluate the use of hospital resources and safety of rifaximin-α treatment in a real-world setting. METHODS: We carried out prospective identification of all patients using rifaximin-α for overt HE. We assessed hospital resource use, bacterial infections, and adverse events during 6-month episodes before and after rifaximin-α initiation. RESULTS: During 26 months we included 127 patients [71.7% male; median age 60.8 years (interquartile range: 56.2-66.1); median model for end-stage liver disease (MELD) score 15.0 (interquartile range: 12.1-20.4); 98% using lactulose treatment]. When comparing the first 6 months after rifaximin-α initiation with the prior 6 months, HE-related hospital admissions decreased (0.86 to 0.41 admissions/patient; p < 0.001), as well as the mean length of stay (8.85 to 3.79 bed days/admission; p < 0.001). No significant differences were found regarding HE-related intensive care unit admissions (0.09 to 0.06 admission/patient; p = 0.253), stay on the intensive care unit (0.43 to 0.57 bed days/admission; p = 0.661), emergency department visits (0.66 to 0.51 visits/patient; p = 0.220), outpatient clinic visits (2.49 to 3.30 bed visits/patient; p = 0.240), or bacterial infections (0.41 to 0.35 infections/patient; p = 0.523). Adverse events were recorded in 2.4% of patients. CONCLUSIONS: The addition of rifaximin-α to lactulose treatment was associated with a significant reduction in the number and length of HE-related hospitalizations for overt HE. Rifaximin-α treatment was well tolerated.

The Yield and Safety of Screening Colonoscopy in Patients Evaluated for Liver Transplantation.

Colorectal cancer (CRC) screening with colonoscopy is commonly used in patients who are candidates for liver transplantation. We initiated this study to define the risk-benefit ratio of performing screening colonoscopy in this population. A retrospective observational study of all consecutive patients undergoing colonoscopy during pre-liver transplantation screening between 2004 and 2017 was conducted. Endoscopic and pathological findings and clinical events potentially related to the colonoscopy in the 30 days after the procedure were registered and compared with a 30-day inpatient control time frame. A total of 858 colonoscopies were performed in 808 patients (65% male; median age, 55 years [interquartile range (IQR), 47-62]; median model for end-stage liver disease (MELD) score, 15 [IQR, 11-18]). CRC was found in 2 patients (0.2%), and advanced adenomas were found in 44 patients (5.4%). The only independent risk factor for an advanced neoplasm was age (odds ratio, 1.072 per year; 95% confidence interval, 1.031-1.115; P < 0.001). During the 30-day postprocedure period, 178 clinical events occurred in 128 patients compared with 101 clinical events in 72 patients in the control time frames (P < 0.001). After colonoscopy, there was a significantly increased risk for renal failure (P = 0.001) and gastrointestinal (GI) bleeding (P = 0.023). Presence of ascites and MELD score were identified as independent risk factors for acute renal failure and GI bleeding. During the study observation period, 53.5% of the screened population actually underwent liver transplantation. Conclusion: CRC screening in pre-liver transplantation patients is associated with a relatively low prevalence of CRC and an increased risk of postcolonoscopy complications such as acute renal failure and GI bleeding, especially in patients with advanced liver disease. Because the risk-benefit ratio of standard performance of a screening colonoscopy in this population appears questionable, alternative screening strategies should be considered.

Variable efficacy of TIPSS in the management of ectopic variceal bleeding: a multicentre retrospective study.

BACKGROUND: Evidence for the efficacy of TIPSS in ectopic variceal bleeding (EctVB) is largely based on relatively small series. AIM: To define the efficacy of TIPSS in EctVB. METHODS: Retrospective analysis of consecutive patients with chronic liver disease who presented with EctVB and received TIPSS in three tertiary centres in 1992-2016. RESULTS: The study included 53 patients (70% male, median age 61 years, median model for end-stage liver disease (MELD) score 11). The ectopic varices were located around the insertion of stomas (40%), duodenum (23%), rectum (17%) and at other sites (20%). Three-quarters of the patients had previously received unsuccessful medical, endoscopic or surgical therapy. The median follow-up was 14.0 months. Following TIPSS, bleeding recurred in 12 patients: 6 of 12 (50%) with duodenal varices, 2 of 9 (22%) with rectal varices and one each with stomal (1/21), intraperitoneal (1/3), hepaticojejunostomy (1/2) and ascending colon varices (1/2). The risk factors for re-bleeding were MELD score at TIPSS placement (HR: 1.081 per point; 95% confidence interval (CI): 1.012-1.153; P = 0.034), varices located at site other than an enterostomy (HR: 9.770; 95%CI: 1.241-76.917; P = 0.030) and previous local therapy (HR: 5.710; 95%CI: 1.211-26.922; P = 0.028). The estimated cumulative re-bleeding rate was 23% at 1 year, 26% at 3 years and 32% at 5 years. Post-TIPSS hepatic encephalopathy manifested or worsened in 16 of 53 patients (30%). CONCLUSION: TIPSS provides long-term control of bleeding in most cirrhotic patients with EctVB. TIPSS is particularly effective in stomal EctVB, the most frequent cause of EctVB, but might not be as effective in duodenal EctVB.

Bacterascites: A study of clinical features, microbiological findings, and clinical significance.

BACKGROUND: Knowledge about bacterascites is limited and management guidelines are based on small patient series. The purpose of this study was to add further insight into the clinical characteristics, microbiological findings, and prognosis of patients diagnosed with bacterascites. METHODS: Retrospective analysis of patients with advanced chronic liver disease diagnosed with bacterascites and SBP between January 2003 and August 2016. RESULTS: In this study, 123 patients were included with 142 episodes of bacterascites. The median MELD score was 20 and clinical symptoms of infection were present in 78%. Empiric antibiotic treatment was initiated in 68%. In 26 untreated patients undergoing repeated paracentesis, 42% were diagnosed with either ongoing bacterascites or SBP. The presence of signs or symptoms of infection was not an independent predictor for mortality or spontaneous resolution of infection. The 1-month and 1-year mortality rates of the 123 patients studied, were 32% and 60%, respectively; these results were in line with data pertaining to the prognosis of SBP. CONCLUSIONS: Patients with bacterascites and SBP are highly comparable with respect to severity of liver disease and overall prognosis. If left untreated, bacterascites is likely to persist or to evolve to SBP in a significant proportion of patients. The results of this study support current guidelines regarding the treatment of ascitic fluid infection, but could not confirm the prognostic relevance of symptomatic disease at the time of diagnosis. We suggest that the threshold to initiate antibiotic treatment, in particular in cases with severely advanced liver disease, should be low.

Microbiology and antibiotic susceptibility patterns in spontaneous bacterial peritonitis: A study of two Dutch cohorts at a 10-year interval.

BACKGROUND: Recent investigations suggest an increasing prevalence of Gram-positive and antibiotic-resistant bacteria causing spontaneous bacterial peritonitis (SBP), probably related to changes in antibiotic prescription patterns, in particular more widespread and long-term use of antibiotic prophylaxis with quinolones. OBJECTIVE: The primary objective of this study was to assess potential changes in the microbiology of SBP in two patient cohorts studied at a 10-year interval. Further aims were to study prognostic factors and outcome of SBP. METHODS: A retrospective double-cohort study, including all ascitic cultures from patients with cirrhosis obtained 2003-2005 and 2013-2014, was conducted. RESULTS: In total 312 patients were included, 125 patients in the first and 187 patients in the second cohort. SBP was diagnosed in 132 of 840 analyzed ascitic fluid samples; 62 samples were culture positive. An increase of Gram-positive bacterial isolates was noted from 26% to 46% between cohorts (p = 0.122). The prevalence of multidrug-antibiotic-resistant pathogens increased from 25% to 32% (p = 0.350). Survival after SBP among the two cohorts was comparable. CONCLUSION: This single-center study in the Netherlands found a modest but nonsignificant increase in the proportion of patients with SBP caused by Gram-positive bacteria and multidrug-antibiotic-resistant bacteria over a 10-year period. Our findings differ from reported data in other countries and suggest empiric antibiotic prophylaxis and treatment of SBP should be based on national and regional microbiological findings and resistance patterns.

The impact of infections on delisting patients from the liver transplantation waiting list.

Approximately 20% of the patients listed for liver transplantation die before transplantation can be accomplished. Understanding risk factors for waiting list mortality may help to improve survival and organ allocation. Infections are very common in patients with cirrhosis and are associated with significant morbidity and mortality. This study analysed the frequency and characteristics of infections in patients awaiting liver transplantation, identified risk factors for withdrawal from the waiting list and evaluated the impact of infections on the clinical outcome. A retrospective analysis of consecutive patients listed for liver transplantation in Rotterdam, the Netherlands from 2007 to 2014 was conducted. Infections occurred in 144 of 327 studied patients (44%). In this cohort, 23.4% of the patients on the liver transplantation waiting list were delisted or died before transplantation. Patients with an infection were 5.2 times more likely to become delisted than noninfected patients. In the 30 days after the first infection, patients were 33.8 times more likely to become delisted compared to noninfected patients. High age, high MELD score, refractory ascites and inappropriate antibiotic therapy were independent predictors for delisting due to infection. Infections occur frequently in patients on the liver transplantation waiting list. Emphasis on appropriate and timely antimicrobial therapy is required.