Clostridium difficile infection(CDI) is the most common nosocomial infection in the United States and is associated with a high mortality. One quarter of patients treated for CDI have at least one recurrence. Spore pe...Clostridium difficile infection(CDI) is the most common nosocomial infection in the United States and is associated with a high mortality. One quarter of patients treated for CDI have at least one recurrence. Spore persistence, impaired host immune response and alteration in the gastrointestinal microbiome due to antibiotic use are factors in recurrent disease. We review the etiology of recurrent CDI and best approaches to management including fecal microbiota transplantation.展开更多
Background and Aims:Acute kidney injury(AKI)is com-mon in patients with cirrhosis but the incidence is heteroge-neous among studies.We performed a meta-analysis to describe the incidence of AKI and its impact on patie...Background and Aims:Acute kidney injury(AKI)is com-mon in patients with cirrhosis but the incidence is heteroge-neous among studies.We performed a meta-analysis to describe the incidence of AKI and its impact on patient mor-tality in patients with cirrhosis.We also evaluated the admis-sion variables predicting development of AKI.Methods:A systematic search of various databases was performed up to November 2018.Meta-analyses were performed using ran-dom effects models.Results:Of 18,474 patients with cirrho-sis from 30 selected studies,5,648 developed AKI,with a pooled incidence of 29%(95% confidence interval[CI]:28-30%,I2 of 99%).In-hospital mortality assessed in eight stud-ies was six-fold higher among AKI patients,as compared to those without AKI(odds ratio[OR]6.72,95%CI:3.47-13,p<0.0001,I2 of 70%).Three studies on patients admitted to intensive care showed about six-fold higher mortality among AKI patients(OR 5.90,95%CI:3.21-10.85,p>0.0001).Mor-tality remained significantly high,at days 30 and 90 and even at 1-year follow up after development of AKI.Of 12 admission variables analyzed,model for end-stage liver disease score,Child-Pugh-Turcotte stage C,presence of ascites,and pres-ence of sepsis/septic shock were statistically significant risk factors for AKI.Conclusions:AKI occurred in about 29% of patients with cirrhosis and is associated with a six-fold in-creased risk of in-hospital mortality.Mortality remained high even in long-term follow-up of 1 year.Patients at risk for AKI development can be recognized at admission.Prospective studies are needed to develop strategies for improving out-come of these patients.展开更多
Acute kidney injury (AKI) occurs frequently in patients with cirrhosis, and hepatorenal syndrome (HRS) is second most common etiology of AKI after volume responsible pre-renal etiology. AKI in these patients negativel...Acute kidney injury (AKI) occurs frequently in patients with cirrhosis, and hepatorenal syndrome (HRS) is second most common etiology of AKI after volume responsible pre-renal etiology. AKI in these patients negatively impacts pre- and post-transplant patient survival and healthcare burden. Re-duced effective blood volume with consequent reduced renal blood flow, along with systemic inflammation in patients with decompensated cirrhosis, result in susceptibility to HRS. In this article, we will review updates over the last 5 years on the changing definition with diagnostic criteria and nomenclature of AKI and HRS, data on medical treatment with vasocon-strictors, and urinary biomarkers in diagnosis of etiology of AKI. We will also discuss the significance of liver trans-plantation evaluation once the diagnosis of HRS is established and the post-transplant immunosuppression management. We will also review one of the challenging issues that remains among transplant-eligible patients, that of allocation of si-multaneous liver kidney transplant. Finally, we will review the new implemented policy from the Organ Procurement Trans-plant Network on simultaneous liver kidney allocation.展开更多
文摘Clostridium difficile infection(CDI) is the most common nosocomial infection in the United States and is associated with a high mortality. One quarter of patients treated for CDI have at least one recurrence. Spore persistence, impaired host immune response and alteration in the gastrointestinal microbiome due to antibiotic use are factors in recurrent disease. We review the etiology of recurrent CDI and best approaches to management including fecal microbiota transplantation.
文摘Background and Aims:Acute kidney injury(AKI)is com-mon in patients with cirrhosis but the incidence is heteroge-neous among studies.We performed a meta-analysis to describe the incidence of AKI and its impact on patient mor-tality in patients with cirrhosis.We also evaluated the admis-sion variables predicting development of AKI.Methods:A systematic search of various databases was performed up to November 2018.Meta-analyses were performed using ran-dom effects models.Results:Of 18,474 patients with cirrho-sis from 30 selected studies,5,648 developed AKI,with a pooled incidence of 29%(95% confidence interval[CI]:28-30%,I2 of 99%).In-hospital mortality assessed in eight stud-ies was six-fold higher among AKI patients,as compared to those without AKI(odds ratio[OR]6.72,95%CI:3.47-13,p<0.0001,I2 of 70%).Three studies on patients admitted to intensive care showed about six-fold higher mortality among AKI patients(OR 5.90,95%CI:3.21-10.85,p>0.0001).Mor-tality remained significantly high,at days 30 and 90 and even at 1-year follow up after development of AKI.Of 12 admission variables analyzed,model for end-stage liver disease score,Child-Pugh-Turcotte stage C,presence of ascites,and pres-ence of sepsis/septic shock were statistically significant risk factors for AKI.Conclusions:AKI occurred in about 29% of patients with cirrhosis and is associated with a six-fold in-creased risk of in-hospital mortality.Mortality remained high even in long-term follow-up of 1 year.Patients at risk for AKI development can be recognized at admission.Prospective studies are needed to develop strategies for improving out-come of these patients.
文摘Acute kidney injury (AKI) occurs frequently in patients with cirrhosis, and hepatorenal syndrome (HRS) is second most common etiology of AKI after volume responsible pre-renal etiology. AKI in these patients negatively impacts pre- and post-transplant patient survival and healthcare burden. Re-duced effective blood volume with consequent reduced renal blood flow, along with systemic inflammation in patients with decompensated cirrhosis, result in susceptibility to HRS. In this article, we will review updates over the last 5 years on the changing definition with diagnostic criteria and nomenclature of AKI and HRS, data on medical treatment with vasocon-strictors, and urinary biomarkers in diagnosis of etiology of AKI. We will also discuss the significance of liver trans-plantation evaluation once the diagnosis of HRS is established and the post-transplant immunosuppression management. We will also review one of the challenging issues that remains among transplant-eligible patients, that of allocation of si-multaneous liver kidney transplant. Finally, we will review the new implemented policy from the Organ Procurement Trans-plant Network on simultaneous liver kidney allocation.
