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Saudi Journal of Kidney Diseases and Transplantation
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Year : 2014  |  Volume : 25  |  Issue : 4  |  Page : 876-880
Urinary tract infection in children with cirrhosis waiting for liver transplantation

1 Gastroenterohepatology Research Center, Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz, Iran
2 Depart-ment of Pediatric Nephrology, Nemazee Teaching Hospital, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran
3 Department of Surgery, Nemazee Teaching Hospital, School of Medicine, Shiraz University of Medical Sciences, Shiraz, Iran

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Date of Web Publication24-Jun-2014

How to cite this article:
Dehghani SM, Basiratnia M, Derakhshan A, Mazidi M, Malek-Hosseini SA. Urinary tract infection in children with cirrhosis waiting for liver transplantation. Saudi J Kidney Dis Transpl 2014;25:876-80

How to cite this URL:
Dehghani SM, Basiratnia M, Derakhshan A, Mazidi M, Malek-Hosseini SA. Urinary tract infection in children with cirrhosis waiting for liver transplantation. Saudi J Kidney Dis Transpl [serial online] 2014 [cited 2023 Feb 8];25:876-80. Available from: https://www.sjkdt.org/text.asp?2014/25/4/876/135189
To the Editor,

Bacterial infections in patients with cirrhosis of the liver are frequently associated with impairment in hepatocellular, renal and circu­latory functions. [1],[2] Patients with cirrhosis have altered immune defenses. Moreover, changes in gut motility, mucosal defense and micro flora allow for translocation of enteric bacteria into mesenteric lymph nodes and the blood stream. [3] Additionally, the cirrhotic liver is in­effective in clearing the bacteria and asso­ciated endotoxins from the blood thus allo­wing for seeding of the sterile peritoneal fluid, resulting in the occurrence of spontaneous bacterial peritonitis (SBP), urinary tract infec­tions (UTI), pneumonia, skin infection and sepsis. [3]

UTI is one of the most prevalent infections in patients with chronic liver disease, and its frequency has been reported to be up to 38.5% in some studies conducted on hospitalized pa-tients. [4] However, only one case study is avai­lable regarding the frequency of this infection in non-hospitalized patients. [5] Because UTI in children can be asymptomatic in many cases, and delayed diagnosis and treatment can lead to irreversible complications, timely diagnosis and treatment are of great importance. [6] This study aims to evaluate the frequency of UTI in non-hospitalized children with chronic liver disease waiting for liver transplantation.

In this prospective, cross-sectional study, a total of 78 non-hospitalized patients younger than 18 years with chronic liver disease of any cause were selected from the Pediatric Gastro-enterology Clinic affiliated to the Shiraz Uni­versity of Medical Sciences. Cirrhosis was diagnosed based on clinical, biochemical, ra-diologic and liver biopsy data. Additionally, the Child-Pugh-Turrcott classification was used to determine the severity and stage of the disease.

Patients with fulminant hepatitis of unknown cause, primary renal disease (acute glomerulo-nephritis or interstitial nephritis), nephrocalci-nosis, as well as renal transplant recipients and patients treated with antibiotics or cortico-steroids were excluded from the study. At the beginning of the study, demographic data (age, sex, underlying disease and complications of cirrhosis) as well as symptoms of UTI (dy-suria, frequency, fever and dribbling) were collected. Urine samples were then obtained from the study subjects by clean catch or mid­stream method. The urine samples were exa­mined for presence of sediment and culture was performed. If the culture was negative and urine sediment was benign, UTI was ruled out. In younger patients who did not have control of voiding, the sample was taken using a catheter. Significant bacteriuria was defined as the growth of more than 10 [5] CFU/mL of a single organism. Pyuria was defined as the presence of >10 leukocytes/mm΃ in a centri-fuged urine sample. The presence of numerous bacteria in urine with no symptoms was con­sidered as asymptomatic bacteriuria. Patients with positive cultures were referred to a neph-rologist for further evaluation.

The study groups were compared using chi-square and Mann-Whitney tests. A P-value <0.05 was considered statistically significant and the results were expressed as mean ± stan­dard deviation.

Written informed consent was obtained from all the parents and the patients, if possible. The study was approved by the Local Ethics Com­mittee of the Shiraz University of Medical Sciences.

In this study, 40 patients (51.3%) were female. The patients' age ranged from four months to 17 years, with a mean age of 6.3 ± 5.1 years. Urine cultures were positive in eight of the 78 patients (10.3%); these patients also had bacteriuria and pyuria. The clinical cha­racteristics of patients with UTI are presented in [Table 1].
Table 1: Clinical characteristics of the patients with chronic liver disease and urinary tract infection.

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The etiology of cirrhosis in the study pa­tients, with and without UTI, is given in [Table 2]. Seven of the eight patients with UTI (87.5%) were female; the mean age of the patients with UTI was lower than those with­out UTI (4.6 ± 3.6 years vs. 6.5 ± 5.3 years; P = 0.329). Ascites was present in 27 children without UTI (38.6%) and four with UTI (50%). The frequency of gastrointestinal blee­ding in patients with and without UTI was 12.5% and 17.1%, respectively.
Table 2: Etiologies of chronic liver disease in the study children and their association with urinary tract

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When we grouped the patients according to the Child-Pugh criteria, there was a predo­minance of patients in the Child B class (n = 37, 47.4%). Among patients with UTI, four (50%) were in Child A class and three (37.5%) were in Child B class. Urine culture revealed E. coli and Klebsiella in three patients each (37.5%), and Staphylococcus species in two patients (25%).

The results of the laboratory tests among patients with and without UTI are shown in [Table 3]. A significant difference was observed between the two groups in albumin level (3.9 ± 0.7 vs 4.5 ± 0.8; P = 0.046) and platelet count (299,000 ± 196,000 vs 169,000 ± 107,000; P = 0.039). Ultrasound was normal in all patients with positive urine culture except one, who had grade II vesicoureteral reflux.
Table 3: Comparison of laboratory values in cirrhotic children with and without urinary tract infection.

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All the organisms grown on culture were sen­sitive to ciprofloxacin but 75% were resistant to cefixime. Sensitivity to other antibiotics (aminoglycosides, nalidixic acid and nitro-furantoin) differed in different cases [Table 1].

Cirrhosis of the liver is one of the most pre­valent forms of acquired immunodeficiency, which is caused by impaired homeostasis, mal­nutrition and/or low serum albumin. [7] SBP, UTI, respiratory infections and bacterimia are frequent infectious complications in cirrhotic patients. [8] The risk factors for these infections include changes in the intestinal flora and the intestinal barrier, decompensated liver disease, fulminant hepatic failure, gastrointestinal blee­ding, history of invasive procedures, impaired immunity of the host defense mechanisms and impaired function of the reticuloendothelial system, complement and neutrophils. The last two risk factors, in fact, represent the most prevalent and serious defects. [7],[9] Compared with the general population, mortality rates are 20-times higher in patients with infections asso­ciated with chronic liver disease. [10]

Some authors have suggested that hepatic failure, [11],[12] tense ascites [12],[13] and increased post-void residual urine [14] could be involved in the high prevalence of bacteriuria in cirrhotic pa­tients. The results of our study did not support this observation as 87.5% of patients with UTI were in Child class A and B; we did not measure the post-void residual urine volume in our patients. Baskin et al [7] mentioned that ascites as well as other intra-abdominal pro­cesses can compromise normal bladder emp­tying, leading to voiding dysfunction, which is a well-described risk factor for UTI in this group of patients. In our study, 50% of the patients with UTI and 38.6% of children with­out UTI had ascites; the difference was not statistically significant.

Although UTI is one of the most prevalent infections in cirrhotic patients (accounting for nearly 30% of all infections), there are few studies in the literature on bacteriuria in chil­dren with cirrhosis. [3],[4],[15] In a study from Brazil on non-hospitalized cirrhotic patients with no symptoms of UTI, urine cultures were positive in 4.9%. [5] In the present study, the prevalence was 10.3%. The higher prevalence in the present study may be due to the lower age of our patients. Also, our study had several exclusion and inclusion criteria and consisted of only non-hospitalized patients.

In this study, pyuria was present in all the patients with UTI and bacteriuria was asymp­tomatic in all, similar to the report of Cruz Rde et al. [5] We also found that bacteriuria occurs more significantly in females. This finding is in line with other studies in which female gender was considered as an important, well-known risk factor. [16] Similarly, Robinowitz et al [17] showed a prevalence of bacteriuria of 32% and 4% in females and males, respectively. In this study, the mean age of the patients with UTI was 4.6 years, which was lower than those without UTI (6.5 year). This finding was in line with the results obtained by Baskin et al. [7] It is well described that, compared with older children, infants and younger children are at a higher risk of incurring acute renal injury. [18]

Although a relationship has been observed between bacterial infection and liver insuffi­ciency in cirrhotic patients, [19] this is not always found. Bellaiche et al [12] found a higher preva­lence of UTI in Child C cirrhotic patients. Recently, Amato et al [2] investigated the preva­lence of bacteriuria in adult patients with cirrhosis of different Child classes and ana­lyzed the associated risk factors. They reported that the Child class in itself did not have any significant relationship with bacteriuria.

Because UTI is usually asymptomatic in chil­dren with cirrhosis, its prevalence must be considered higher than what it seems. More­over, due to the impaired immune system of the cirrhotic patients, a urine analysis is suggested to be performed for these patients as a routine.

   Acknowledgments Top

The authors thank the Local Research Ethics Committee of Shiraz University of Medical Sciences for approving this research. Thanks are also conveyed to the Research Improvement Center of Shiraz University of Medical Sciences and Ms. Afsaneh Keivanshekouh for improving the use of English in the manuscript.

The present article was extracted from the thesis written by Maryam Mazidi and was financially supported by the Shiraz University of Medical Sciences grants No 87-4056.

   References Top

1.Borzio M, Salerno F, Piantoni L, et al. Bacterial infection in patients with advanced cirrhosis: A multicentre prospective study. Dig Liver Dis 2001;33:41-8.  Back to cited text no. 1
2.Amato A, Precone DF, Carannante N, et al. Pre­valence and risk factors for bacteriuria in patients with cirrhosis. Infez Med 2005;13: 103-8.  Back to cited text no. 2
3.Ghassemi S, Garcia-Tsao G. Prevention and treatment of infections in patients with cirrhosis. Best Pract Res Clin Gastroenterol 2007;21:77-93.  Back to cited text no. 3
4.Yang YY, Lin HC. Bacterial infections in patients with cirrhosis. J Chin Med Assoc 2005; 68:447-51.  Back to cited text no. 4
5.Cruz Rde C, Tanajura D, Almeida D, Cruz M, Paraná R. Urinary tract infection in non-hospitalized patients with cirrhosis and no symptoms of uri­nary tract infection: A case series study. Braz J Infect Dis 2006;10:380-3.  Back to cited text no. 5
6.Westphal JF, Jehl F, Vetter D. Pharmacological, toxicologic, and microbiological considerations in the choice of initial antibiotic therapy for serious infections in patients with cirrhosis of the liver. Clin Infect Dis 1994;18: 324-35.  Back to cited text no. 6
7.Baskin E, Ozçay F, Sakalli H, et al. Frequency of urinary tract infection in pediatric liver transplan­tation candidates. Pediatr Transplant 2007;11:402-7.  Back to cited text no. 7
8.Navasa M, Rimola A, Rodes J. Bacterial infec­tions in liver disease. Semin Liver Dis 1997;17 (4):323-33.  Back to cited text no. 8
9.Wyke RJ. Bacterial infections complicating liver disease. Bailliere's Clin Gastroenterol 1989;3: 187-210.  Back to cited text no. 9
10.Bica I, McGovern B, Dhar R, et al. Increasing mortality due to end-stage liver disease in patients with human immunodeficiency virus infection. Clin Infect Dis 2001;32:492-7.  Back to cited text no. 10
11.Caly WR, Strauss E. A prospective study of bacterial infections in patients with cirrhosis. J Hepatol 1993;18:353-8.  Back to cited text no. 11
12.Bellaiche G, Pauwels A, Levy VG, Tordjmann T, Levy VG. Asymptomatic urinary infection is frequent in hospitalized patients with cirrho-sis. Gastroenterol Clin Biol 1994;18:96-7.  Back to cited text no. 12
13.Cadranel JF, Denis J, Pauwels A, et al. Preva­lence and risk factors of bacteriuria in cirrhotic patients: a prospective case-control multicenter study in 244 patients. J Hepatol 1999;31(3):464-8.  Back to cited text no. 13
14.Bercoff E, Dechelotte P, Weber J, Morcamp D, Denis P, Bourreille J. Urinary tract infection in cirrhotic patients, a urodynamic explanation. Lancet 1985;325:987.  Back to cited text no. 14
15.Fernondez J, Navasa M, Gomez J, et al. Bacterial infections in cirrhosis: Epidemio-logical changes with invasive procedures and norfloxacin pro­phylaxis. Hepatology 2002;35: 140-8.  Back to cited text no. 15
16.Winberg J, Andersen HJ, Bergstrom T, Jacobsson B, Larson H, Lincoln K. Epidemio­logy of symptomatic urinary tract infection in childhood. Acta Paediatr 1974;63:1-20.  Back to cited text no. 16
17.Rabinowitz CB, Song JH, Movson JS, et al. Cholecysto-urachal fistula. Abdom Imaging 2007;32:108-10.  Back to cited text no. 17
18.Representatives L. Practice Parameter: The Diag­nosis, Treatment, and Evaluation of the Initial Urinary Tract Infection in Febrile Infants and Young Children. American Academy of Pediatrics. Committee on Quality Improvement. Subcom­mittee on Urinary Tract Infection. Pediatrics 1999;103:843-52.  Back to cited text no. 18

Correspondence Address:
Seyed Mohsen Dehghani
Gastroenterohepatology Research Center, Shiraz Transplant Research Center, Shiraz University of Medical Sciences, Shiraz
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/1319-2442.135189

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