Alimentary Pharmacology and Therapeutics Invited Editorials REFERENCES 1. Arvaniti V, D’Amico G, Fede G, et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010; 139: 1246–56. 2. Sundaram V, Kaung A, Rajaram A, et al. Obesity is independently associated with infection in hospitalised patients with end-stage liver disease. Aliment Pharmacol Ther 2015; 42: 1271–80. 3. Ng M, Fleming T, Robinson M, et al. Global, regional, and national prevalence of overweight and obesity in children and adults during 1980-2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 2014; 384: 766–81. 4. Loomba R, Sanyal AJ. The global NAFLD epidemic. Nat Rev Gastroenterol Hepatol 2013; 10: 686–90. 5. Loomba R, Yang HI, Su J, Brenner D, Iloeje U, Chen CJ. Obesity and alcohol synergize to increase the risk of incident
Editorial: obesity in chronic liver diseases – increased infections; authors’ reply V. Sundaram*,† & R. Jalan‡ *Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA. † Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA. ‡ Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, London, UK. E-mail: [email protected] doi:10.1111/apt.13483
We thank Dr Singh and Prof Loomba for their thoughtful editorial regarding our study evaluating the association between obesity and infection risk in hospitalised patients with end-stage liver disease.1, 2 As infection is the primary cause of mortality in end-stage liver disease, it is essential to determine and address potential risk factors for infection in this population.3 As an association between obesity and infection has been observed in the general population, our study sought to determine if this association also occurred among patients with cirrhosis.4 In our study, we categorised patients as non-obese, obesity class I–II and obesity class III. Our findings demonstrated a positive association between obesity and infection, with the greatest odds ratio for patients with class III obesity. Furthermore, the distribution of infection sites differed between obese and non-obese patients with end-stage liver disease, with obese patients having greater prevalence of bacteraemia, urinary tract infection and skin/soft tissue infection. We believe that given these
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7.
8. 9. 10.
hepatocellular carcinoma in men. Clin Gastroenterol Hepatol 2010; 8: 891–8. Loomba R, Bettencourt R, Barrett-Connor E. Synergistic association between alcohol intake and body mass index with serum alanine and aspartate aminotransferase levels in older adults: the Rancho Bernardo Study. Aliment Pharmacol Ther 2009; 30: 1137–49. Hart CL, Morrison DS, Batty GD, Mitchell RJ, Davey Smith G. Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies. BMJ 2010; 340: c1240. Falagas ME, Kompoti M. Obesity and infection. Lancet Infect Dis 2006; 6: 438–46. Dhurandhar NV, Bailey D, Thomas D. Interaction of obesity and infections. Obes Rev 2015; 16: 1017–29. Fantuzzi G, Faggioni R. Leptin in the regulation of immunity, inflammation, and hematopoiesis. J Leukoc Biol 2000; 68: 437–46.
findings, the clinician should have a low threshold for infection screening in this population, particularly skin/ soft tissue infection, which may be overlooked in obese patients given their large body habitus and potential for poor mobility. As Dr Singh and Prof Loomba have noted, there are limitations with the study related to the use of an administrative database. We believe these are partially addressed by the large sample size and use of validated algorithms to identify the population, exposure and outcome. However, our findings need further corroboration in prospective studies. Our hope is that our study will provide the impetus for further research to confirm the association between obesity and infection risk, establish the pathophysiologic reasons for this association, and determine the effect of weight management on reducing infection prevalence in this fragile population.
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.2
REFERENCES 1. Singh S, Loomba R. Editorial: obesity in chronic liver diseases increased infections. Aliment Pharmacol Ther 2016; 43: 311. 2. Sundaram V, Kaung A, Rajaram A, et al. Obesity is independently associated with infection in hospitalised patients with end-stage liver disease. Aliment Pharmacol Ther 2015; 42: 1271–80. 3. Arvaniti V, D’Amico G, Fede G, et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010; 139: 1246–56.e5. 4. Falagas ME, Kompoti M. Obesity and infection. Lancet Infect Dis 2006; 6: 438–46.
Aliment Pharmacol Ther 2016; 43: 311–312 ª 2015 John Wiley & Sons Ltd
Editorial: obesity in chronic liver diseases – increased infections; authors’ reply V. Sundaram*,† & R. Jalan‡ *Division of Gastroenterology, Cedars-Sinai Medical Center, Los Angeles, CA, USA. † Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA, USA. ‡ Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, London, UK. E-mail: [email protected] doi:10.1111/apt.13483
We thank Dr Singh and Prof Loomba for their thoughtful editorial regarding our study evaluating the association between obesity and infection risk in hospitalised patients with end-stage liver disease.1, 2 As infection is the primary cause of mortality in end-stage liver disease, it is essential to determine and address potential risk factors for infection in this population.3 As an association between obesity and infection has been observed in the general population, our study sought to determine if this association also occurred among patients with cirrhosis.4 In our study, we categorised patients as non-obese, obesity class I–II and obesity class III. Our findings demonstrated a positive association between obesity and infection, with the greatest odds ratio for patients with class III obesity. Furthermore, the distribution of infection sites differed between obese and non-obese patients with end-stage liver disease, with obese patients having greater prevalence of bacteraemia, urinary tract infection and skin/soft tissue infection. We believe that given these
312
6.
7.
8. 9. 10.
hepatocellular carcinoma in men. Clin Gastroenterol Hepatol 2010; 8: 891–8. Loomba R, Bettencourt R, Barrett-Connor E. Synergistic association between alcohol intake and body mass index with serum alanine and aspartate aminotransferase levels in older adults: the Rancho Bernardo Study. Aliment Pharmacol Ther 2009; 30: 1137–49. Hart CL, Morrison DS, Batty GD, Mitchell RJ, Davey Smith G. Effect of body mass index and alcohol consumption on liver disease: analysis of data from two prospective cohort studies. BMJ 2010; 340: c1240. Falagas ME, Kompoti M. Obesity and infection. Lancet Infect Dis 2006; 6: 438–46. Dhurandhar NV, Bailey D, Thomas D. Interaction of obesity and infections. Obes Rev 2015; 16: 1017–29. Fantuzzi G, Faggioni R. Leptin in the regulation of immunity, inflammation, and hematopoiesis. J Leukoc Biol 2000; 68: 437–46.
findings, the clinician should have a low threshold for infection screening in this population, particularly skin/ soft tissue infection, which may be overlooked in obese patients given their large body habitus and potential for poor mobility. As Dr Singh and Prof Loomba have noted, there are limitations with the study related to the use of an administrative database. We believe these are partially addressed by the large sample size and use of validated algorithms to identify the population, exposure and outcome. However, our findings need further corroboration in prospective studies. Our hope is that our study will provide the impetus for further research to confirm the association between obesity and infection risk, establish the pathophysiologic reasons for this association, and determine the effect of weight management on reducing infection prevalence in this fragile population.
ACKNOWLEDGEMENT The authors’ declarations of personal and financial interests are unchanged from those in the original article.2
REFERENCES 1. Singh S, Loomba R. Editorial: obesity in chronic liver diseases increased infections. Aliment Pharmacol Ther 2016; 43: 311. 2. Sundaram V, Kaung A, Rajaram A, et al. Obesity is independently associated with infection in hospitalised patients with end-stage liver disease. Aliment Pharmacol Ther 2015; 42: 1271–80. 3. Arvaniti V, D’Amico G, Fede G, et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010; 139: 1246–56.e5. 4. Falagas ME, Kompoti M. Obesity and infection. Lancet Infect Dis 2006; 6: 438–46.
Aliment Pharmacol Ther 2016; 43: 311–312 ª 2015 John Wiley & Sons Ltd
