Spontaneous fungal peritonitis: Micro-organisms, management and mortality in liver cirrhosis-A systematic review

BACKGROUND Spontaneous peritonitis is an infection of ascitic fluid without a known intraabdominal source of infection. spontaneous fungal peritonitis (SFP) is a potentially fatal complication of decompensated cirrhosis, defined as fungal infection of ascitic fluid in the presence of ascitic neutrophil count of greater than 250 cells/mL. AIM To determine the prevalence of fungal pathogens, management and outcomes (mortality) of SFP in critically ill cirrhotic patients. METHODS Studies were identified using PubMed, EMBASE, Cochrane Central Register of Controlled Trials and Scopus databases until February 2019. Inclusion criteria included intervention trials and observation studies describing the association between SFP and cirrhosis. The primary outcome was in-hospital, 1-mo, and 6- mo mortality rates of SFP in cirrhotic patients. Secondary outcomes were fungal microorganisms identified and in hospital management by anti-fungal medications. The National Heart, Lung and Blood Institute quality assessment tools were used to assess internal validity and risk of bias for each included study. RESULTS Six observational studies were included in this systematic review. The overall quality of included studies was good. A meta-analysis of results could not be performed because of differences in reporting of outcomes and heterogeneity of the included studies. There were 82 patients with SFP described across all the included studies. Candida species, predominantly Candida albicans was the fungal pathogen in majority of the cases (48%-81.8%) followed by Candida krusei (15%- 25%) and Candida glabrata (6.66%-20%). Cryptococcus neoformans (53.3%) was the other major fungal pathogen. Antifungal therapy in SFP patients was utilized in 33.3% to 81.8% cases. The prevalence of in hospital mortality ranged from 33.3% to 100%, whereas 1-mo mortality ranged between 50% to 73.3%. CONCLUSION This systematic review suggests that SFP in end stage liver disease patient is associated with high mortality both in the hospital and at 1-mo, and that antifungal therapy is currently underutilized.

Secondary angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease: Results from the nationwide inpatient sample

BACKGROUND Chronic kidney disease is associated with angiodysplasia of gastrointestinal tract leading to increased risk of gastrointestinal bleeding.AIM To determine the nationwide prevalence,trends,predictors and resource utilization of angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease hospitalizations.METHODS The Nationwide Inpatient Sample database from 2009 to 2014,was utilized to conduct a retrospective study on patients with angiodysplasia associatedgastrointestinal bleeding and end-stage renal disease.Hospitalizations with endstage renal disease were included in the Nationwide Inpatient Sample database and a subset of hospitalizations with end-stage renal disease and angiodysplasiaassociated gastrointestinal bleeding were identified with International Classification of Diseases,9th revision,Clinical Modification codes for both endstage renal disease(585.6)and angiodysplasia(569.85,537.83).RESULTS The prevalence of angiodysplasia-associated gastrointestinal bleeding was 0.45%(n=24709)among all end-stage renal disease patients(n=5505252)that were hospitalized.Multivariate analysis indicated that the following were significant factors associated with higher odds of angiodysplasia associated-gastrointestinal bleeding in end-stage renal disease patients:an increasing trend from 2009-2014(P<0.01),increasing age(P<0.0001);African American race(P=0.0206);increasing Charlson-Deyo Comorbidity Index(P<0.01);hypertension(P<0.0001);and tobacco use(P<0.0001).Diabetes mellitus(P<0.0001)was associated with lower odds of angiodysplasia associated-gastrointestinal bleeding in end-stage renal disease patients.In comparison with urban teaching hospitals,rural and urban nonteaching hospitals were associated with decreased odds of angiodysplasia associated-gastrointestinal hemorrhage.CONCLUSION Angiodysplasia-associated gastrointestinal bleeding in end-stage renal disease patients showed an increasing trend from 2009-2014.Advanced age,African American race,overall high comorbidities,hypertension and smoking were significant factors for angiodysplasia-associated gastrointestinal bleeding in bleeding in these patients.