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German Soriano - One of the best experts on this subject based on the ideXlab platform.

  • secondary Bacterial Peritonitis in cirrhosis a retrospective study of clinical and analytical characteristics diagnosis and management
    Journal of Hepatology, 2010
    Co-Authors: German Soriano, Jose Castellote, Ana Girbau, Cristina Alvarez, Jordi Gordillo, Carme Baliellas, Meritxell Casas, Carles Pons, Eva Roman
    Abstract:

    Background & Aims Secondary Bacterial Peritonitis in cirrhotic patients is an uncommon entity that has been little reported. Our aim is to analyse the frequency, clinical characteristics, treatment and prognosis of patients with secondary Peritonitis in comparison to those of patients with spontaneous Bacterial Peritonitis (SBP). Methods Retrospective analysis of 24 cirrhotic patients with secondary Peritonitis compared with 106 SBP episodes. Results Secondary Peritonitis represented 4.5% of all Peritonitis in cirrhotic patients. Patients with secondary Peritonitis showed a significantly more severe local inflammatory response than patients with SBP. Considering diagnosis of secondary Peritonitis, the sensitivity of Runyon's criteria was 66.6% and specificity 89.7%, Runyon's criteria and/or polymicrobial ascitic fluid culture were present in 95.6%, and abdominal computed tomography was diagnostic in 85% of patients in whom diagnosis was confirmed by surgery or autopsy. Mortality during hospitalization was higher in patients with secondary Peritonitis than in those with SBP (16/24, 66.6% vs. 28/106, 26.4%) ( p p =0.21). Considering surgically treated patients, the time between diagnostic paracentesis and surgery was shorter in survivors than in non-survivors (3.2±2.4 vs. 7.2±6.1days, p =0.31). Conclusions Secondary Peritonitis is an infrequent complication in cirrhotic patients but mortality is high. A low threshold of suspicion on the basis of Runyon's criteria and microbiological data, together with an aggressive approach that includes prompt abdominal computed tomography and early surgical evaluation, could improve prognosis in these patients.

  • primary prophylaxis of spontaneous Bacterial Peritonitis delays hepatorenal syndrome and improves survival in cirrhosis
    Gastroenterology, 2007
    Co-Authors: Javier Fernández, German Soriano, Ramon Planas, Miquel Navasa, Silvia Montoliu, David Monfort, Carmen Vila, Alberto Pardo, Enrique Quintero, Victor Vargas
    Abstract:

    Background & Aims: Norfloxacin is highly effective in preventing spontaneous Bacterial Peritonitis recurrence in cirrhosis, but its role in the primary prevention of this complication is uncertain. Methods: Patients with cirrhosis and low protein ascitic levels ( Results: Norfloxacin administration reduced the 1-year probability of developing spontaneous Bacterial Peritonitis (7% vs 61%, P P = .02), and improved the 3-month (94% vs 62%, P = .003) and the 1-year (60% vs 48%, P = .05) probability of survival compared with placebo. Conclusions: Primary prophylaxis with norfloxacin has a great impact in the clinical course of patients with advanced cirrhosis. It reduces the incidence of spontaneous Bacterial Peritonitis, delays the development of hepatorenal syndrome, and improves survival.

  • effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous Bacterial Peritonitis
    The New England Journal of Medicine, 1999
    Co-Authors: Pau Sort, German Soriano, Victor Vargas, Miquel Navasa, R Planas, Vicente Arroyo, Xavier Aldeguer, Luis Ruizdelarbol, Lluis Castells, Monica Guevara
    Abstract:

    Background In patients with cirrhosis and spontaneous Bacterial Peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients. Methods We randomly assigned 126 patients with cirrhosis and spontaneous Bacterial Peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in doses that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization. Results The infection resolved in 59 patients in the cefotaxime group (94 percent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 percent) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eighteen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6 (10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients treated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had the highest values. Conclusions In patients with cirrhosis and spontaneous Bacterial Peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone. (N Engl J Med 1999;341:403-9.)

  • effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous Bacterial Peritonitis
    The New England Journal of Medicine, 1999
    Co-Authors: Pau Sort, German Soriano, Victor Vargas, Miquel Navasa, R Planas, Vicente Arroyo, Xavier Aldeguer, Luis Ruizdelarbol, Lluis Castells, Monica Guevara
    Abstract:

    Background In patients with cirrhosis and spontaneous Bacterial Peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients. Methods We randomly assigned 126 patients with cirrhosis and spontaneous Bacterial Peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in doses that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization. Results The infection resolved in 59 patients in the cefotaxime group (94 percent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 percent) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eighteen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6 (10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients treated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had the highest values. Conclusions In patients with cirrhosis and spontaneous Bacterial Peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone. (N Engl J Med 1999;341:403-9.)

  • effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous Bacterial Peritonitis
    The New England Journal of Medicine, 1999
    Co-Authors: Pau Sort, German Soriano, Victor Vargas, Miquel Navasa, R Planas, Vicente Arroyo, Xavier Aldeguer, Luis Ruizdelarbol, Lluis Castells, Monica Guevara
    Abstract:

    Background In patients with cirrhosis and spontaneous Bacterial Peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients. Methods We randomly assigned 126 patients with cirrhosis and spontaneous Bacterial Peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in doses that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization. Results The infection resolved in 59 patients in the cefotaxime group (94 percent...

Carlos Guarner - One of the best experts on this subject based on the ideXlab platform.

  • risk of a first community acquired spontaneous Bacterial Peritonitis in cirrhotics with low ascitic fluid protein levels
    Gastroenterology, 1999
    Co-Authors: Carlos Guarner, Miriam Sabat, Maria Teresa Novella, German Soriano, Jordi Ortiz, R. Sola, Montserrat Andreu, Maria Carmen Vila, Susana Coll, C Gomez
    Abstract:

    Abstract Background & Aims: Long-term primary antibiotic prophylaxis of spontaneous Bacterial Peritonitis has been suggested to be useful in cirrhotic patients with low ascitic fluid protein levels. However, it is unlikely that all such patients need prophylactic treatment. The aim of this study was to identify the group of cirrhotic patients with low ascitic fluid protein levels at high risk of developing a first episode of spontaneous Bacterial Peritonitis during outpatient follow-up. Methods: One hundred nine cirrhotic patients with low ascitic fluid protein levels and without previous episodes of spontaneous Bacterial Peritonitis were followed up in an outpatient clinic. Results: Twenty-eight patients developed a first spontaneous Bacterial Peritonitis episode. In the multivariate analysis, serum bilirubin level (>3.2 mg /dL) and platelet count ( 3 ) independently correlated with the risk of developing the first spontaneous Bacterial Peritonitis ( P P 1.09) were established. The probability of developing a first spontaneous Bacterial Peritonitis episode at 1-year follow-up was significantly higher in the high risk-group (low-risk group, 23.6%; high-risk group, 55%; P P P Conclusions: Cirrhotic patients with low ascitic fluid protein levels (≤1 g /dL) and high bilirubin level and/or low platelet count are at high risk of developing a first episode of spontaneous Bacterial Peritonitis during long-term follow-up.

  • continuous versus inpatient prophylaxis of the first episode of spontaneous Bacterial Peritonitis with norfloxacin
    Hepatology, 1997
    Co-Authors: Maria Teresa Novella, Jordi Gana, Miriam Sabat, Susanna Coll, Maria Vila, German Soriano, Jordi Ortiz, R. Sola, Montserrat Andreu, Carlos Guarner
    Abstract:

    Cirrhotic patients with ascites and low ascitic fluid total protein and/or high serum bilirubin levels are at high risk to develop the first episode of spontaneous Bacterial Peritonitis during long-term follow-up. The aim of the present study was to determine the efficacy of continuous long-term selective intestinal decontamination with norfloxacin in the prevention of this complication. One hundred nine cirrhotic patients with ascites and ascitic fluid total protein levels of ⩽ 1 g/dL or serum bilirubin levels of > 2.5 mg/dL without previous spontaneous Bacterial Peritonitis were prospectively randomized into two groups: group 1 (n = 56) received norfloxacin, 400 mg daily administered orally, and group 2 (n = 53) was the long-term control group, receiving norfloxacin only during hospitalization. During a mean follow-up of 43 +/- 3 weeks, there was one spontaneous Bacterial Peritonitis (1.8%) in group 1 and 9 (16.9%) in group 2 (P < .01). The incidence of community-acquired spontaneous Bacterial Peritonitis was lower in group 1 (1.8% vs. 13.2%, P < .05), whereas the incidence of nosocomial spontaneous Bacterial Peritonitis (0% vs. 3.7%) and the incidence of extraperitoneal infections (25% vs. 24.5%) were similar in both groups (P = NS). The actuarial probability of survival at 18 months was 75% in group 1 and 62% in group 2 (P = NS). Resistance to norfloxacin was observed in 9 of 10 (90%) Escherichia coli isolated in infections from group 1 and in 4 of 11 (36.3%) from group 2 (P < .05). The overall incidence of infections caused by norfloxacin-resistant bacteria was higher in group 1 (19.6% vs. 15%), but it did not reach statistical significance. Continuous long-term selective intestinal decontamination with norfloxacin is effective in preventing the first spontaneous Bacterial Peritonitis in cirrhotic patients at high risk. However, the emergence of infections caused by norfloxacin-resistant bacteria must be weighed carefully against the benefits of continuous long-term prophylaxis.

  • continuous versus inpatient prophylaxis of the first episode of spontaneous Bacterial Peritonitis with norfloxacin
    Hepatology, 1997
    Co-Authors: Maria Teresa Novella, Jordi Gana, Miriam Sabat, Susanna Coll, Maria Vila, German Soriano, Jordi Ortiz, R. Sola, Montserrat Andreu, Carlos Guarner
    Abstract:

    Cirrhotic patients with ascites and low ascitic fluid total protein and/or high serum bilirubin levels are at high risk to develop the first episode of spontaneous Bacterial Peritonitis during long-term follow-up. The aim of the present study was to determine the efficacy of continuous long-term selective intestinal decontamination with norfloxacin in the prevention of this complication. One hundred nine cirrhotic patients with ascites and ascitic fluid total protein levels of 2.5 mg/dL without previous spontaneous Bacterial Peritonitis were prospectively randomized into two groups: group 1 (n = 56) received norfloxacin, 400 mg daily administered orally, and group 2 (n = 53) was the long-term control group, receiving norfloxacin only during hospitalization. During a mean follow-up of 43 +/- 3 weeks, there was one spontaneous Bacterial Peritonitis (1.8%) in group 1 and 9 (16.9%) in group 2 (P < .01). The incidence of community-acquired spontaneous Bacterial Peritonitis was lower in group 1 (1.8% vs. 13.2%, P < .05), whereas the incidence of nosocomial spontaneous Bacterial Peritonitis (0% vs. 3.7%) and the incidence of extraperitoneal infections (25% vs. 24.5%) were similar in both groups (P = NS). The actuarial probability of survival at 18 months was 75% in group 1 and 62% in group 2 (P = NS). Resistance to norfloxacin was observed in 9 of 10 (90%) Escherichia coli isolated in infections from group 1 and in 4 of 11 (36.3%) from group 2 (P < .05). The overall incidence of infections caused by norfloxacin-resistant bacteria was higher in group 1 (19.6% vs. 15%), but it did not reach statistical significance. Continuous long-term selective intestinal decontamination with norfloxacin is effective in preventing the first spontaneous Bacterial Peritonitis in cirrhotic patients at high risk. However, the emergence of infections caused by norfloxacin-resistant bacteria must be weighed carefully against the benefits of continuous long-term prophylaxis.

  • spontaneous Bacterial Peritonitis
    Seminars in Liver Disease, 1997
    Co-Authors: Carlos Guarner, German Soriano
    Abstract:

    Spontaneous Bacterial Peritonitis (SBP) is considered a Bacterial infection of ascitic fluid without any intraabdominal, surgically treatable source of infection. Multiple variants of this infection with a different clinical setting and outcome have been described during the past decade. Bacterial translocation from the gut to mesenteric lymph nodes, depressed activity of the reticuloendothelial phagocytic system and decreased antimicrobial capacity of ascitic fluid seem to be the main steps in the pathogenesis of ascitic fluid infection. Diagnosis of ascitic fluid infection is based on clinical suspicion and analysis of ascitic fluid, especially white cell count and culture in blood culture bottles. A low threshold for performing an abdominal paracentesis is the key for an early diagnosis and treatment. A third-generation cephalosporin is the treatment of choice, achieving a cure rate higher than 80%. Nonazotemic patients with nonadvanced, uncomplicated SBP may be treated with oral ofloxacin. Prophylactic selective intestinal decontamination with oral norfloxacin is extremely useful in preventing SBP in patients that are at high risk for developing SBP, such as hospitalized cirrhotic patients with gastrointestinal hemorrhage or low ascitic fluid total protein. Primary or secondary long-term prophylaxis of SBP also decreases the incidence of SBP, but these patients should be carefully observed for detecting possible infections caused by quinolone-resistant organisms. Since long-term prognosis of SBP patients is poor, survivors should be considered for liver transplantation.

  • randomized comparative study of oral ofloxacin versus intravenous cefotaxime in spontaneous Bacterial Peritonitis
    Gastroenterology, 1996
    Co-Authors: Miquel Navasa, Antoni Rimola, Carlos Guarner, Montserrat Forne, Francesc Marco, Josep M. Llovet, A Follo, G Clemente, V Vargas, R Planas
    Abstract:

    Abstract BACKGROUND & AIMS: Treatment of spontaneous Bacterial Peritonitis currently involves intravenous antibiotic administration. To test the possibility of treating spontaneous Bacterial Peritonitis with oral antibiotics, oral ofloxacin was compared with intravenous cefotaxime in this infection. METHODS: One hundred twenty-three cirrhotics with uncomplicated spontaneous Bacterial Peritonitis (no septic shock, grade II-IV hepatic encephalopathy, serum creatinine level of > 3 mg/dL, and gastrointestinal hemorrhage or ileus) were randomly given oral ofloxacin (64 patients) or intravenous cefotaxime (59 patients). RESULTS: Infection resolution rate was 84% in the ofloxacin group and 85% in the cefotaxime group. Peak serum levels and trough serum and ascitic fluid levels of ofloxacin and cefotaxime measured on days 3 (23 patients) and 6 (11 patients) of therapy were greater than the minimal inhibitory concentration of isolated organisms. Hospital survival rate was 81% in each group of patients. Blood urea nitrogen and hepatic encephalopathy at diagnosis were associated with prognosis. None of the 36 nonazotemic patients with community-acquired spontaneous Bacterial Peritonitis and without hepatic encephalopathy developed complications during hospitalization, and all were alive at time of discharge. CONCLUSIONS: Oral ofloxacin is as effective as intravenous cefotaxime in uncomplicated spontaneous Bacterial Peritonitis. Nonazotemic cirrhotic patients with uncomplicated community-acquired spontaneous Bacterial Peritonitis and without hepatic encephalopathy have an excellent prognosis and may be treated with oral ofloxacin without requiring hospitalization. (Gastroenterology 1996 Oct;111(4):1011-7)

Miquel Navasa - One of the best experts on this subject based on the ideXlab platform.

  • primary prophylaxis of spontaneous Bacterial Peritonitis delays hepatorenal syndrome and improves survival in cirrhosis
    Gastroenterology, 2007
    Co-Authors: Javier Fernández, German Soriano, Ramon Planas, Miquel Navasa, Silvia Montoliu, David Monfort, Carmen Vila, Alberto Pardo, Enrique Quintero, Victor Vargas
    Abstract:

    Background & Aims: Norfloxacin is highly effective in preventing spontaneous Bacterial Peritonitis recurrence in cirrhosis, but its role in the primary prevention of this complication is uncertain. Methods: Patients with cirrhosis and low protein ascitic levels ( Results: Norfloxacin administration reduced the 1-year probability of developing spontaneous Bacterial Peritonitis (7% vs 61%, P P = .02), and improved the 3-month (94% vs 62%, P = .003) and the 1-year (60% vs 48%, P = .05) probability of survival compared with placebo. Conclusions: Primary prophylaxis with norfloxacin has a great impact in the clinical course of patients with advanced cirrhosis. It reduces the incidence of spontaneous Bacterial Peritonitis, delays the development of hepatorenal syndrome, and improves survival.

  • renal failure in patients with cirrhosis and sepsis unrelated to spontaneous Bacterial Peritonitis value of meld score
    Gastroenterology, 2005
    Co-Authors: Carlos Terra, Miquel Navasa, Javier Fernández, Monica Guevara, Aldo Torre, Rosa Gilabert, Marta Martinllahi, Maria E Baccaro, C Bru, Vicente Arroyo
    Abstract:

    Background & Aims: Although renal failure is a common complication of sepsis and patients with cirrhosis frequently develop sepsis, there have been no studies specifically assessing renal function in patients with cirrhosis and sepsis unrelated to spontaneous Bacterial Peritonitis. The aim of this study was to investigate prospectively the frequency, characteristics, and outcome of renal failure in patients with cirrhosis and sepsis unrelated to spontaneous Bacterial Peritonitis. Methods: One hundred six consecutive patients with cirrhosis and sepsis were studied prospectively. Patients with spontaneous Bacterial Peritonitis were excluded. Results: Twenty-nine out of 106 patients (27%) with cirrhosis and sepsis developed acute renal failure as compared with only 8 of 100 patients (8%) from a control group of cirrhotic patients without infection (P < .0001). Renal failure in the sepsis group was reversible in 22 (76%; 21% of all patients) patients and nonreversible in 7 (24%; 6% of all patients) patients. Renal failure was associated with impairment of effective arterial blood volume, without evidence of tubular damage. The occurrence and type of renal failure correlated strongly with mortality (mortality at 3 months: nonreversible renal failure, 100%; reversible renal failure, 55%; no renal failure, 13%). Among variables obtained at diagnosis of sepsis, the Model for End-Stage Liver Disease (MELD) score was the only independent predictive factor of mortality. Conclusions: Renal failure is common in patients with cirrhosis and sepsis unrelated to spontaneous Bacterial Peritonitis and is associated with arterial underfilling and renal vasoconstriction. Outcome is poor, even in the setting of reversible renal failure. The MELD score is the best prognostic marker of patients with cirrhosis and sepsis.

  • diagnosis treatment and prophylaxis of spontaneous Bacterial Peritonitis a consensus document
    Journal of Hepatology, 2000
    Co-Authors: Antoni Rimola, Ramon Planas, Miquel Navasa, Guadalupe Garciatsao, Laura J V Piddock, B Bernard, John M Inadomi
    Abstract:

    Bacterial Peritonitis (SBP) is a fre- quent and severe complication of cirrhotic patients with ascites. Much information regarding SBP has ap- peared during recent years, particularly on aspects in- volving the management of this complication. There- fore, the International Ascites Club (IAC) com- missioned a panel of experts to prepare a consensus on the diagnosis, therapy and prophylaxis of SBI? A draft consensus document, drawn up by the panel members, was presented and discussed at the regular Meeting of the IAC held during the 33rd Annual Meeting of the European Association for the Study of the Liver, in Lisbon in April 1998, after which a final consensus was reached. This article represents the final consensus document and is divided into three separate sections concerning the diagnosis, treatment and prophylaxis of SBI? Speci- fic recommendations are formulated and each recom- mendation is rated on the basis of strength and quality according to guidelines from the Practice Guidelines Committee of the American Association for the Study of Liver Diseases, with some modifications (1). The rating system is summarized in Table 1.

  • effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous Bacterial Peritonitis
    The New England Journal of Medicine, 1999
    Co-Authors: Pau Sort, German Soriano, Victor Vargas, Miquel Navasa, R Planas, Vicente Arroyo, Xavier Aldeguer, Luis Ruizdelarbol, Lluis Castells, Monica Guevara
    Abstract:

    Background In patients with cirrhosis and spontaneous Bacterial Peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients. Methods We randomly assigned 126 patients with cirrhosis and spontaneous Bacterial Peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in doses that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization. Results The infection resolved in 59 patients in the cefotaxime group (94 percent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 percent) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eighteen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6 (10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients treated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had the highest values. Conclusions In patients with cirrhosis and spontaneous Bacterial Peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone. (N Engl J Med 1999;341:403-9.)

  • effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous Bacterial Peritonitis
    The New England Journal of Medicine, 1999
    Co-Authors: Pau Sort, German Soriano, Victor Vargas, Miquel Navasa, R Planas, Vicente Arroyo, Xavier Aldeguer, Luis Ruizdelarbol, Lluis Castells, Monica Guevara
    Abstract:

    Background In patients with cirrhosis and spontaneous Bacterial Peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients. Methods We randomly assigned 126 patients with cirrhosis and spontaneous Bacterial Peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in doses that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization. Results The infection resolved in 59 patients in the cefotaxime group (94 percent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 percent) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eighteen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6 (10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients treated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had the highest values. Conclusions In patients with cirrhosis and spontaneous Bacterial Peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone. (N Engl J Med 1999;341:403-9.)

Vicente Arroyo - One of the best experts on this subject based on the ideXlab platform.

  • restricted use of albumin for spontaneous Bacterial Peritonitis
    Gut, 2007
    Co-Authors: Javier Fernández, Vicente Arroyo, Samuel H Sigal, Carmen Stanca, Miguel Navasa
    Abstract:

    Spontaneous Bacterial Peritonitis (SBP) may precipitate deterioration of circulatory function with severe hepatic insufficiency, hepatic encephalopathy, and type-1 hepatorenal syndrome (HRS) and has 30% hospital mortality despite infection resolution.1 Predictors of this acute-on-chronic liver failure include ascitic fluid concentrations of granulocytes and cytokines and renal and hepatic insufficiency at diagnosis.1–3 Endotoxemia and the inflammatory response precipitate renal failure (RF) by accentuating splanchnic vasodilatation and impairing cardiac function.3–5 Compensatory activation of the renin-angiotensin and sympathetic nervous systems further decrease renal perfusion. Volume expansion with albumin (1.5 g/kg day one, 1 g/kg day three) significantly reduces the incidence of HRS and hospital mortality.2 In the sole reported trial, only patients with serum bilirubin (bili) >68.4 μmol/l, blood urea nitrogen (BUN) >30 mg/dl or serum creatinine (Cr) >88.4 μmol/l appeared …

  • renal failure in patients with cirrhosis and sepsis unrelated to spontaneous Bacterial Peritonitis value of meld score
    Gastroenterology, 2005
    Co-Authors: Carlos Terra, Miquel Navasa, Javier Fernández, Monica Guevara, Aldo Torre, Rosa Gilabert, Marta Martinllahi, Maria E Baccaro, C Bru, Vicente Arroyo
    Abstract:

    Background & Aims: Although renal failure is a common complication of sepsis and patients with cirrhosis frequently develop sepsis, there have been no studies specifically assessing renal function in patients with cirrhosis and sepsis unrelated to spontaneous Bacterial Peritonitis. The aim of this study was to investigate prospectively the frequency, characteristics, and outcome of renal failure in patients with cirrhosis and sepsis unrelated to spontaneous Bacterial Peritonitis. Methods: One hundred six consecutive patients with cirrhosis and sepsis were studied prospectively. Patients with spontaneous Bacterial Peritonitis were excluded. Results: Twenty-nine out of 106 patients (27%) with cirrhosis and sepsis developed acute renal failure as compared with only 8 of 100 patients (8%) from a control group of cirrhotic patients without infection (P < .0001). Renal failure in the sepsis group was reversible in 22 (76%; 21% of all patients) patients and nonreversible in 7 (24%; 6% of all patients) patients. Renal failure was associated with impairment of effective arterial blood volume, without evidence of tubular damage. The occurrence and type of renal failure correlated strongly with mortality (mortality at 3 months: nonreversible renal failure, 100%; reversible renal failure, 55%; no renal failure, 13%). Among variables obtained at diagnosis of sepsis, the Model for End-Stage Liver Disease (MELD) score was the only independent predictive factor of mortality. Conclusions: Renal failure is common in patients with cirrhosis and sepsis unrelated to spontaneous Bacterial Peritonitis and is associated with arterial underfilling and renal vasoconstriction. Outcome is poor, even in the setting of reversible renal failure. The MELD score is the best prognostic marker of patients with cirrhosis and sepsis.

  • A randomized unblinded pilot study comparing albumin versus hydroxyethyl starch in spontaneous Bacterial Peritonitis
    Hepatology (Baltimore Md.), 2005
    Co-Authors: Javier Fernández, Joan Monteagudo, Xavier Bargalló, Wladimiro Jiménez, Jaume Bosch, Vicente Arroyo, Miguel Navasa
    Abstract:

    The administration of albumin improves circulatory function, prevents hepatorenal syndrome, and reduces hospital mortality in patients with cirrhosis and spontaneous Bacterial Peritonitis. This randomized unblinded pilot study compared the effect of albumin (10 patients) and the synthetic plasma expander hydroxyethyl starch 200/0.5 (10 patients) on the systemic hemodynamics of patients with spontaneous Bacterial Peritonitis. Baseline measurements were performed within 12 hours after diagnosis of infection. Patients then received 2 doses of the volume expander (1.5 g/kg body weight after baseline measurements and 1 g/kg body weight on day 3). Measurements were repeated after infection resolution. Treatment with albumin was associated with a significant increase in arterial pressure and a suppression of plasma renin activity, indicating an improvement in circulatory function. This occurred in the setting of a significant expansion of central blood volume (increase in cardiopulmonary pressures and atrial natriuretic factor) and an increase in systolic volume and systemic vascular resistance. In contrast, no significant changes were observed in these parameters in patients treated with hydroxyethyl starch. Von Willebrand-related antigen plasma levels significantly decreased in patients treated with albumin but not in those treated with hydroxyethyl starch. Serum nitrates and nitrites increased in patients treated with hydroxyethyl starch but not in those treated with albumin. These data suggest an effect of albumin on endothelial function. In conclusion, albumin but not hydroxyethyl starch improves systemic hemodynamics in patients with spontaneous Bacterial Peritonitis. This effect is due not only to volume expansion but also to an action on the peripheral arterial circulation.

  • effect of intravenous albumin on systemic and hepatic hemodynamics and vasoactive neurohormonal systems in patients with cirrhosis and spontaneous Bacterial Peritonitis
    Journal of Hepatology, 2004
    Co-Authors: Javier Fernández, Wladimiro Jiménez, Jaume Bosch, Miguel Navasa, Juan Carlos Garciapagan, Juan Gabraldes, Vicente Arroyo
    Abstract:

    Abstract Background/Aims Albumin administration prevents renal failure and improves survival in spontaneous Bacterial Peritonitis. This study characterizes the mechanisms of action of albumin in this condition. Methods Systemic and splanchnic hemodynamics, plasma renin activity and plasma concentration of interleukin-6, serum concentration of nitric oxide and ascitic fluid levels of nitric oxide and interleukin-6 were assessed at diagnosis and resolution of infection in 12 patients with spontaneous Bacterial Peritonitis treated with ceftriaxone plus albumin. At infection resolution there was a significant improvement in circulatory function, as indicated by a significant increase in mean arterial pressure (+8%, P =0.02), a fall in heart rate (−10%, P =0.01), a suppression of plasma renin activity (−67%, P =0.002) and a decrease in creatinine levels. These changes were related to both an increase in cardiac work (stroke work index: +18%, P =0.005) and in peripheral vascular resistance (+14%, P =0.05). The improvement in cardiac function was due to an increase in filling. No significant changes were observed in portal pressure or hepatic blood flow. Conclusions These results indicate that the beneficial effects of albumin administration on systemic hemodynamics and renal function in spontaneous Bacterial Peritonitis are related to both an improvement in cardiac function and a decrease in the degree of arterial vasodilation.

  • effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous Bacterial Peritonitis
    The New England Journal of Medicine, 1999
    Co-Authors: Pau Sort, German Soriano, Victor Vargas, Miquel Navasa, R Planas, Vicente Arroyo, Xavier Aldeguer, Luis Ruizdelarbol, Lluis Castells, Monica Guevara
    Abstract:

    Background In patients with cirrhosis and spontaneous Bacterial Peritonitis, renal function frequently becomes impaired. This impairment is probably related to a reduction in effective arterial blood volume and is associated with a high mortality rate. We conducted a study to determine whether plasma volume expansion with intravenous albumin prevents renal impairment and reduces mortality in these patients. Methods We randomly assigned 126 patients with cirrhosis and spontaneous Bacterial Peritonitis to treatment with intravenous cefotaxime (63 patients) or cefotaxime and intravenous albumin (63 patients). Cefotaxime was given daily in doses that varied according to the serum creatinine level, and albumin was given at a dose of 1.5 g per kilogram of body weight at the time of diagnosis, followed by 1 g per kilogram on day 3. Renal impairment was defined as nonreversible deterioration of renal function during hospitalization. Results The infection resolved in 59 patients in the cefotaxime group (94 percent) and 62 in the cefotaxime-plus-albumin group (98 percent) (P=0.36). Renal impairment developed in 21 patients in the cefotaxime group (33 percent) and 6 in the cefotaxime-plus-albumin group (10 percent) (P=0.002). Eighteen patients (29 percent) in the cefotaxime group died in the hospital, as compared with 6 (10 percent) in the cefotaxime-plus-albumin group (P=0.01); at three months, the mortality rates were 41 percent (a total of 26 deaths) and 22 percent (a total of 14 deaths), respectively (P=0.03). Patients treated with cefotaxime had higher levels of plasma renin activity than those treated with cefotaxime and albumin; patients with renal impairment had the highest values. Conclusions In patients with cirrhosis and spontaneous Bacterial Peritonitis, treatment with intravenous albumin in addition to an antibiotic reduces the incidence of renal impairment and death in comparison with treatment with an antibiotic alone. (N Engl J Med 1999;341:403-9.)

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  • risk of a first community acquired spontaneous Bacterial Peritonitis in cirrhotics with low ascitic fluid protein levels
    Gastroenterology, 1999
    Co-Authors: Carlos Guarner, Miriam Sabat, Maria Teresa Novella, German Soriano, Jordi Ortiz, R. Sola, Montserrat Andreu, Maria Carmen Vila, Susana Coll, C Gomez
    Abstract:

    Abstract Background & Aims: Long-term primary antibiotic prophylaxis of spontaneous Bacterial Peritonitis has been suggested to be useful in cirrhotic patients with low ascitic fluid protein levels. However, it is unlikely that all such patients need prophylactic treatment. The aim of this study was to identify the group of cirrhotic patients with low ascitic fluid protein levels at high risk of developing a first episode of spontaneous Bacterial Peritonitis during outpatient follow-up. Methods: One hundred nine cirrhotic patients with low ascitic fluid protein levels and without previous episodes of spontaneous Bacterial Peritonitis were followed up in an outpatient clinic. Results: Twenty-eight patients developed a first spontaneous Bacterial Peritonitis episode. In the multivariate analysis, serum bilirubin level (>3.2 mg /dL) and platelet count ( 3 ) independently correlated with the risk of developing the first spontaneous Bacterial Peritonitis ( P P 1.09) were established. The probability of developing a first spontaneous Bacterial Peritonitis episode at 1-year follow-up was significantly higher in the high risk-group (low-risk group, 23.6%; high-risk group, 55%; P P P Conclusions: Cirrhotic patients with low ascitic fluid protein levels (≤1 g /dL) and high bilirubin level and/or low platelet count are at high risk of developing a first episode of spontaneous Bacterial Peritonitis during long-term follow-up.

  • continuous versus inpatient prophylaxis of the first episode of spontaneous Bacterial Peritonitis with norfloxacin
    Hepatology, 1997
    Co-Authors: Maria Teresa Novella, Jordi Gana, Miriam Sabat, Susanna Coll, Maria Vila, German Soriano, Jordi Ortiz, R. Sola, Montserrat Andreu, Carlos Guarner
    Abstract:

    Cirrhotic patients with ascites and low ascitic fluid total protein and/or high serum bilirubin levels are at high risk to develop the first episode of spontaneous Bacterial Peritonitis during long-term follow-up. The aim of the present study was to determine the efficacy of continuous long-term selective intestinal decontamination with norfloxacin in the prevention of this complication. One hundred nine cirrhotic patients with ascites and ascitic fluid total protein levels of ⩽ 1 g/dL or serum bilirubin levels of > 2.5 mg/dL without previous spontaneous Bacterial Peritonitis were prospectively randomized into two groups: group 1 (n = 56) received norfloxacin, 400 mg daily administered orally, and group 2 (n = 53) was the long-term control group, receiving norfloxacin only during hospitalization. During a mean follow-up of 43 +/- 3 weeks, there was one spontaneous Bacterial Peritonitis (1.8%) in group 1 and 9 (16.9%) in group 2 (P < .01). The incidence of community-acquired spontaneous Bacterial Peritonitis was lower in group 1 (1.8% vs. 13.2%, P < .05), whereas the incidence of nosocomial spontaneous Bacterial Peritonitis (0% vs. 3.7%) and the incidence of extraperitoneal infections (25% vs. 24.5%) were similar in both groups (P = NS). The actuarial probability of survival at 18 months was 75% in group 1 and 62% in group 2 (P = NS). Resistance to norfloxacin was observed in 9 of 10 (90%) Escherichia coli isolated in infections from group 1 and in 4 of 11 (36.3%) from group 2 (P < .05). The overall incidence of infections caused by norfloxacin-resistant bacteria was higher in group 1 (19.6% vs. 15%), but it did not reach statistical significance. Continuous long-term selective intestinal decontamination with norfloxacin is effective in preventing the first spontaneous Bacterial Peritonitis in cirrhotic patients at high risk. However, the emergence of infections caused by norfloxacin-resistant bacteria must be weighed carefully against the benefits of continuous long-term prophylaxis.

  • continuous versus inpatient prophylaxis of the first episode of spontaneous Bacterial Peritonitis with norfloxacin
    Hepatology, 1997
    Co-Authors: Maria Teresa Novella, Jordi Gana, Miriam Sabat, Susanna Coll, Maria Vila, German Soriano, Jordi Ortiz, R. Sola, Montserrat Andreu, Carlos Guarner
    Abstract:

    Cirrhotic patients with ascites and low ascitic fluid total protein and/or high serum bilirubin levels are at high risk to develop the first episode of spontaneous Bacterial Peritonitis during long-term follow-up. The aim of the present study was to determine the efficacy of continuous long-term selective intestinal decontamination with norfloxacin in the prevention of this complication. One hundred nine cirrhotic patients with ascites and ascitic fluid total protein levels of 2.5 mg/dL without previous spontaneous Bacterial Peritonitis were prospectively randomized into two groups: group 1 (n = 56) received norfloxacin, 400 mg daily administered orally, and group 2 (n = 53) was the long-term control group, receiving norfloxacin only during hospitalization. During a mean follow-up of 43 +/- 3 weeks, there was one spontaneous Bacterial Peritonitis (1.8%) in group 1 and 9 (16.9%) in group 2 (P < .01). The incidence of community-acquired spontaneous Bacterial Peritonitis was lower in group 1 (1.8% vs. 13.2%, P < .05), whereas the incidence of nosocomial spontaneous Bacterial Peritonitis (0% vs. 3.7%) and the incidence of extraperitoneal infections (25% vs. 24.5%) were similar in both groups (P = NS). The actuarial probability of survival at 18 months was 75% in group 1 and 62% in group 2 (P = NS). Resistance to norfloxacin was observed in 9 of 10 (90%) Escherichia coli isolated in infections from group 1 and in 4 of 11 (36.3%) from group 2 (P < .05). The overall incidence of infections caused by norfloxacin-resistant bacteria was higher in group 1 (19.6% vs. 15%), but it did not reach statistical significance. Continuous long-term selective intestinal decontamination with norfloxacin is effective in preventing the first spontaneous Bacterial Peritonitis in cirrhotic patients at high risk. However, the emergence of infections caused by norfloxacin-resistant bacteria must be weighed carefully against the benefits of continuous long-term prophylaxis.

  • risk factors for spontaneous Bacterial Peritonitis in cirrhotic patients with ascites
    Gastroenterology, 1993
    Co-Authors: Montserrat Andreu, R. Sola, Susana Coll, Antonio Sitgesserra, C Alia, M Gallen, Carmen M Vila, Maria Isabel Oliver
    Abstract:

    Abstract Background: This study was performed to investigate the risk factors for a first episode of spontaneous Bacterial Peritonitis in cirrhotic patients. Methods: One hundred ten cirrhotics with sterile ascites, without previous spontaneous Bacterial Peritonitis (SBP), were included from March 1988 to October 1989 and followed up until October 1990 (follow-up, 46 ± 3.5 weeks; range, 4–120 weeks). Results: Twenty-eight patients (25.45%) suffered SBP. In multivariate analysis (Cox's regression model) including only variables commonly used in clinical practice, ascitic fluid protein concentration and serum bilirubin level independently correlated with first SBP development. Using these two variables the relative risk of a first SBP episode was calculated for each patient. According to the median relative risk coefficient (1.2), a low-risk group (relative risk, 1.2) were established. Kaplan-Meier estimates of patients free of SBP were significantly higher in the low-risk group. Conclusions: The probability of a first SBP episode is significantly influenced by the antimicrobial capacity of ascitic fluid and hepatic function.