Limits...
Risk factors and outcome in patients with primary sclerosing cholangitis with persistent biliary candidiasis.

Rupp C, Bode KA, Chahoud F, Wannhoff A, Friedrich K, Weiss KH, Sauer P, Stremmel W, Gotthardt DN - BMC Infect. Dis. (2014)

Bottom Line: We retrospectively analysed patients diagnosed with PSC who were admitted to our department during 2002 to 2012.A subgroup analysis showed reduced survival with a greater necessity for orthotopic liver transplantation (OLT) only in patients with persistence of Candida (p = 0.007).In a multivariate regression analysis that included Mayo risk score (MRS), sex, age, dominant stenosis, inflammatory bowel disease, autoimmune hepatitis overlap syndrome, and number of times ERC was performed, biliary candidiasis was an independent risk factor for reduced survival (p = 0.008).

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine IV, University Hospital of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany. Daniel.gotthardt@med.uni-heidelberg.de.

ABSTRACT

Background: Candidiasis is commonly observed in patients with primary sclerosing cholangitis (PSC), but the clinical risk factors associated with its presence have not been fully investigated. In this study, we aimed to analyse the incidence, risk factors, and transplantation-free survival in primary sclerosing cholangitis (PSC) patients with persistent biliary candidiasis.

Methods: We retrospectively analysed patients diagnosed with PSC who were admitted to our department during 2002 to 2012. One-hundred fifty patients whose bile cultures were tested for fungal species were selected, and their clinical and laboratory parameters were investigated. The results of endoscopic retrograde cholangiography (ERC) and bile cultures were analysed using chart reviews. The cases of biliary candidiasis were sub-classified as transient or persistent.

Results: Thirty out of 150 (20.0%) patients had biliary candidiasis. Although all patients demonstrated comparable baseline characteristics, those with biliary candidiasis showed significantly reduced transplantation-free survival (p < 0.0001) along with a markedly elevated frequency of cholangiocarcinoma (CCA) (p = 0.04). The patients were further sub-classified according to the transient (15/30) or persistent (15/30) nature of their biliary candidiasis. A subgroup analysis showed reduced survival with a greater necessity for orthotopic liver transplantation (OLT) only in patients with persistence of Candida (p = 0.007). The survival in the patients with transient biliary candidiasis was comparable to that in candidiasis-free patients. In a multivariate regression analysis that included Mayo risk score (MRS), sex, age, dominant stenosis, inflammatory bowel disease, autoimmune hepatitis overlap syndrome, and number of times ERC was performed, biliary candidiasis was an independent risk factor for reduced survival (p = 0.008). Risk factors associated with acquisition of biliary candidiasis were age at PSC diagnosis and number of ERCs.

Conclusions: The persistence of biliary candidiasis is associated with markedly reduced transplantation-free survival in PSC patients. By contrast, actuarial survival in patients with transient biliary candidiasis approaches that for patients without any evidence of biliary candidiasis. Further studies on the treatment of persistent biliary candidiasis in patients with PSC are warranted.

Show MeSH

Related in: MedlinePlus

Kaplan–Meier analysis of actuarial transplantation-free survival (n = 150). The survival is given in years from the time of first diagnosis. Patients with biliary candidiasis had reduced survival compared to patients without candidiasis (A). Patients with transient biliary candidiasis showed no difference in survival rates (B), whereas patients with persistent biliary candidiasis had markedly reduced survival (C).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
getmorefigures.php?uid=PMC4209225&req=5

Fig2: Kaplan–Meier analysis of actuarial transplantation-free survival (n = 150). The survival is given in years from the time of first diagnosis. Patients with biliary candidiasis had reduced survival compared to patients without candidiasis (A). Patients with transient biliary candidiasis showed no difference in survival rates (B), whereas patients with persistent biliary candidiasis had markedly reduced survival (C).

Mentions: The patients with bile cultures positive for Candida showed a markedly elevated frequency of CCA (p = 0.04), although there was no difference between the 2 subgroups. The mean time interval between detection of Candida in the bile and CCA diagnosis was 2.2 years. Of note, three of the five patients with CCA were diagnosed with candidiasis at the same time as their initial CCA diagnosis. Patients with candidiasis needed orthotopic liver transplantation (OLT) more often, and they more often reached the combined endpoint (OLT: p = 0.007; death/OLT combined: p < 0.0001). All patients died due to CCA. A subgroup analysis revealed elevated frequencies of OLT and reaching the combined endpoint only in the patients with persistent candidiasis (p = 0.003 and p = 0.004, respectively) (Table 2). These results were confirmed by Kaplan-Meier analysis. The patients with candidiasis showed a markedly reduced transplantation-free survival than those without Candida (log-rank: p < 0.001). Remarkably, only the patients with persistent candidiasis showed reduced transplantation-free survival (log-rank: p = 0.002) (Figure 2A-C).Figure 2


Risk factors and outcome in patients with primary sclerosing cholangitis with persistent biliary candidiasis.

Rupp C, Bode KA, Chahoud F, Wannhoff A, Friedrich K, Weiss KH, Sauer P, Stremmel W, Gotthardt DN - BMC Infect. Dis. (2014)

Kaplan–Meier analysis of actuarial transplantation-free survival (n = 150). The survival is given in years from the time of first diagnosis. Patients with biliary candidiasis had reduced survival compared to patients without candidiasis (A). Patients with transient biliary candidiasis showed no difference in survival rates (B), whereas patients with persistent biliary candidiasis had markedly reduced survival (C).
© Copyright Policy - open-access
Related In: Results  -  Collection

License 1 - License 2
Show All Figures
getmorefigures.php?uid=PMC4209225&req=5

Fig2: Kaplan–Meier analysis of actuarial transplantation-free survival (n = 150). The survival is given in years from the time of first diagnosis. Patients with biliary candidiasis had reduced survival compared to patients without candidiasis (A). Patients with transient biliary candidiasis showed no difference in survival rates (B), whereas patients with persistent biliary candidiasis had markedly reduced survival (C).
Mentions: The patients with bile cultures positive for Candida showed a markedly elevated frequency of CCA (p = 0.04), although there was no difference between the 2 subgroups. The mean time interval between detection of Candida in the bile and CCA diagnosis was 2.2 years. Of note, three of the five patients with CCA were diagnosed with candidiasis at the same time as their initial CCA diagnosis. Patients with candidiasis needed orthotopic liver transplantation (OLT) more often, and they more often reached the combined endpoint (OLT: p = 0.007; death/OLT combined: p < 0.0001). All patients died due to CCA. A subgroup analysis revealed elevated frequencies of OLT and reaching the combined endpoint only in the patients with persistent candidiasis (p = 0.003 and p = 0.004, respectively) (Table 2). These results were confirmed by Kaplan-Meier analysis. The patients with candidiasis showed a markedly reduced transplantation-free survival than those without Candida (log-rank: p < 0.001). Remarkably, only the patients with persistent candidiasis showed reduced transplantation-free survival (log-rank: p = 0.002) (Figure 2A-C).Figure 2

Bottom Line: We retrospectively analysed patients diagnosed with PSC who were admitted to our department during 2002 to 2012.A subgroup analysis showed reduced survival with a greater necessity for orthotopic liver transplantation (OLT) only in patients with persistence of Candida (p = 0.007).In a multivariate regression analysis that included Mayo risk score (MRS), sex, age, dominant stenosis, inflammatory bowel disease, autoimmune hepatitis overlap syndrome, and number of times ERC was performed, biliary candidiasis was an independent risk factor for reduced survival (p = 0.008).

View Article: PubMed Central - PubMed

Affiliation: Department of Internal Medicine IV, University Hospital of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany. Daniel.gotthardt@med.uni-heidelberg.de.

ABSTRACT

Background: Candidiasis is commonly observed in patients with primary sclerosing cholangitis (PSC), but the clinical risk factors associated with its presence have not been fully investigated. In this study, we aimed to analyse the incidence, risk factors, and transplantation-free survival in primary sclerosing cholangitis (PSC) patients with persistent biliary candidiasis.

Methods: We retrospectively analysed patients diagnosed with PSC who were admitted to our department during 2002 to 2012. One-hundred fifty patients whose bile cultures were tested for fungal species were selected, and their clinical and laboratory parameters were investigated. The results of endoscopic retrograde cholangiography (ERC) and bile cultures were analysed using chart reviews. The cases of biliary candidiasis were sub-classified as transient or persistent.

Results: Thirty out of 150 (20.0%) patients had biliary candidiasis. Although all patients demonstrated comparable baseline characteristics, those with biliary candidiasis showed significantly reduced transplantation-free survival (p < 0.0001) along with a markedly elevated frequency of cholangiocarcinoma (CCA) (p = 0.04). The patients were further sub-classified according to the transient (15/30) or persistent (15/30) nature of their biliary candidiasis. A subgroup analysis showed reduced survival with a greater necessity for orthotopic liver transplantation (OLT) only in patients with persistence of Candida (p = 0.007). The survival in the patients with transient biliary candidiasis was comparable to that in candidiasis-free patients. In a multivariate regression analysis that included Mayo risk score (MRS), sex, age, dominant stenosis, inflammatory bowel disease, autoimmune hepatitis overlap syndrome, and number of times ERC was performed, biliary candidiasis was an independent risk factor for reduced survival (p = 0.008). Risk factors associated with acquisition of biliary candidiasis were age at PSC diagnosis and number of ERCs.

Conclusions: The persistence of biliary candidiasis is associated with markedly reduced transplantation-free survival in PSC patients. By contrast, actuarial survival in patients with transient biliary candidiasis approaches that for patients without any evidence of biliary candidiasis. Further studies on the treatment of persistent biliary candidiasis in patients with PSC are warranted.

Show MeSH
Related in: MedlinePlus