Fecal Microbiota Transplantation for Clostridioides Difficile Infection in Patients with Chronic Liver Disease

Background. Fecal microbiota transplantation (FMT) is a well-established therapeutic option for patients with antibiotic resistant Clostridioides difficile infection (CDI). However, the efficacy of FMT in patients with chronic liver disease remains elusive. Aims. We studied the effect of FMT on chronic liver disease (CLD) patients with CDI at our tertiary medical center. Methods. A cohort of all patients who received FMT from December 2012 to May 2014 for refractory or recurrent CDI was identified. Patients were monitored for a year after FMT. Descriptive analysis was conducted to compare the effect of FMT in patients with and without CLD. Results. A total of 201 patients with CDI received FMT, 14 of which had a history of CLD. Nine of these patients exhibited cirrhosis of the liver with a mean Child-Turcotte-Pugh score of 8. CDI development in these patients was associated with recent exposure to antibiotics and was observed to be significantly different between both groups (17% of CLD patients vs. 58% in the general cohort, p=0.01). Four patients with CLD received \u3e1 FMT, of which 2 did not respond to treatment. There was no significant difference between patients with liver disease and the rest of the cohort with regard to FMT response (12/14 (87%) vs. 164/187 (88%), p=0.68). Conclusion. FMT is a safe and effective therapy against CDI for patients with CLD and cirrhosis

Hypercalcemia in renal transplant patient with Pneumocystis jirovecii pneumonia

Pneumoncystis jirovecii (PJP) is an opportunistic infection that can occur in immunosuppressed patients, including those with renal transplant. We present the case of a 63-year old male with autosomal-dominant polycystic kidney disease with renal transplant on immunosuppressive therapy who presented with cough and exertional dyspnea. He was hypoxic with coarse breath sounds bilaterally. CT chest revealed ground-glass opacities with increased interstitial markings of the left lung. Labs were significant for hypercalcemia with ionized calcium 1.53 mmol/L, parathyroid hormone 97 pg/mL, 25-hydroxy vitamin D level 30 ng/mL and increased 1,25-dihydroxy vitamin D to 156 pg/mL. He was started on intravenous normal saline, furosemide and calcitonin, however, he remained hypercalcemic. Endocrinology evaluated him and he was started on ketoconazole and received one dose of denosumab, with no improvement in calcium levels. Bronchiolar lavage cultures obtained from bronchoscopy were positive for PJP. He was started on intravenous steroids, clindamycin and primaquine due to acute kidney injury, precluding the use of Bactrim. His calcium levels improved with treatment of PJP, and he was discharged home. This case illustrates the potential for renal transplant recipients who develop PJP to develop hypercalcemia. Although the mechanism is not fully understood, it is thought to be secondary to an increase in 1,25-dihydroxy vitamin D, possibly related to a granulomatous reaction against PJP. Patients with PJP may have hypercalcemia that improves with treatment, as was seen in this patient. It is important to consider PJP as the etiology of unexplained hypercalcemia in renal transplant patients.https://scholarlycommons.henryford.com/merf2020caserpt/1113/thumbnail.jp

Novel Therapies in Hepatic Encephalopathy

Despite widespread use of lactulose and rifaximin for the treatment of hepatic encephalopathy, this complication of advanced liver disease remains a major burden on the health care system in the United States and continues to predispose to high morbidity and mortality. Several agents have surfaced over recent years with promise to treat hepatic encephalopathy and mitigate the cognitive impairment associated with this disease process. The purpose of this article is to highlight the leading emerging therapies in hepatic encephalopathy as well as their therapeutic targets

Fecal Microbiota Transplantation for Clostridioides Difficile Infection in Patients with Chronic Liver Disease

Background. Fecal microbiota transplantation (FMT) is a well-established therapeutic option for patients with antibiotic resistant Clostridioides difficile infection (CDI). However, the efficacy of FMT in patients with chronic liver disease remains elusive. Aims. We studied the effect of FMT on chronic liver disease (CLD) patients with CDI at our tertiary medical center. Methods. A cohort of all patients who received FMT from December 2012 to May 2014 for refractory or recurrent CDI was identified. Patients were monitored for a year after FMT. Descriptive analysis was conducted to compare the effect of FMT in patients with and without CLD. Results. A total of 201 patients with CDI received FMT, 14 of which had a history of CLD. Nine of these patients exhibited cirrhosis of the liver with a mean Child-Turcotte-Pugh score of 8. CDI development in these patients was associated with recent exposure to antibiotics and was observed to be significantly different between both groups (17% of CLD patients vs. 58% in the general cohort, p=0.01). Four patients with CLD received >1 FMT, of which 2 did not respond to treatment. There was no significant difference between patients with liver disease and the rest of the cohort with regard to FMT response (12/14 (87%) vs. 164/187 (88%), p=0.68). Conclusion. FMT is a safe and effective therapy against CDI for patients with CLD and cirrhosis

Correlation Between Bilirubinemia and Acute Kidney Injury in Patients with Cirrhosis

Background: Acute kidney injury (AKI) in the setting of cirrhosis is associated with significant morbidity. However, data is limited regarding the role that hyperbilirubinemia plays in renal injury. One proposed mechanism is direct renal tubular injury from bilirubin and bile salts, but this is not well elucidated. Using a tertiary care population, we aimed to evaluate whether serum bilirubin levels predict the likelihood of AKI in patients with cirrhosis, as well as predict the probability of renal recovery in this population. Methods: Hospitalized patients with cirrhosis, with and without AKI, were retrospectively identified from January 2012-December 2015. AKI was defined per KDIGO criteria and classified into HRS type 1, HRS type 2, and/or acute tubular necrosis (ATN). Other etiologies of AKI were excluded. Data concerning patient demographics, MELD-Na score, peak total serum bilirubin during hospi-talization, change in total serum bilirubin from baseline, peak serum creatinine (SCr) during hospitalization, change in SCr from baseline, and nadir estimated glomerular filtration rate (eGFR) were analyzed. In patients with AKI, renal recovery was evaluated after 6 months of follow up and was defined as a return of SCr towards baseline or a lack of dialysis dependence. Results: A total of 200 cirrhotic patients were included. The majority were Caucasian (70%), male (62%), and had alcoholic cirrhosis (61%) as the etiology of their liver disease. Of these, 57% had AKI, while 43% did not. The average peak total bilirubin was significantly higher in patients with AKI compared to patients without AKI (13.6 mg/dL vs. 5.0 mg/dL respectively; p\u3c 0.001). The change in bilirubin from baseline was significantly higher in patients with AKI compared to patients without AKI (8.7 mg/dL vs. 2.5 mg/dL respectively; p\u3c 0.001). Patients\u27 peak bilirubin level also correlated with their peak SCr (p\u3c 0.001), change in SCr (p=0.004), and nadir eGFR (p=0.004) during hospitalization. There was no significant difference in peak bilirbuin levels between HRS type 1, HRS type 2, and ATN. While peak bilirubin level was unable to predict the likelihood of renal recovery among patients with AKI, a lower MELD-Na score was predictive of renal recovery (p=0.015). Conclusions: Higher bilirubin levels predicted both an increased likelihood of and severity of AKI, manifested as both higher SCr and lower nadir eGFR. Elevated bilirubin also correlated with the development of both HRS and ATN, suggesting that hyperbilirubinemia may play a role in the pathogenesis of AKI, irrespective of etiology. Measured bilirubin did not predict renal recovery in cirrhotic patients with AKI. Further data on the association between hyperbilirubinemia and AKI can guide clinicians to risk stratify and plan initiation of dialysis. Identification of the pathogenic mechanisms may also lead to directed therapy