Retrospective Cohort Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Nov 27, 2021; 13(11): 1777-1790
Published online Nov 27, 2021. doi: 10.4254/wjh.v13.i11.1777
Nonalcoholic fatty liver disease is associated with worse intestinal complications in patients hospitalized for Clostridioides difficile infection
Yi Jiang, Salil Chowdhury, Bing-Hong Xu, Mohamad Aghaie Meybodi, Konstantinos Damiris, Samanthika Devalaraju, Nikolaos Pyrsopoulos
Yi Jiang, Salil Chowdhury, Mohamad Aghaie Meybodi, Konstantinos Damiris, Samanthika Devalaraju, Department of Medicine, Rutgers New Jersey Medical School, Newark, NJ 07101, United States
Bing-Hong Xu, Liver Center and Center for Asian Health, RWJBH-Saint Barnabas Medical Center, Florham Park, NJ 07932, United States
Nikolaos Pyrsopoulos, Department of Medicine, Gastroenterology and Hepatology, Rutgers New Jersey Medical School, Newark, NJ 07101, United States
Author contributions: Jiang Y and Pyrsopoulos N planned and designed the study; Chowdhury S, Xu BH, Meybodi MA, Damiris K and Devalaraju S conducted the data collection and interpretation; Jiang Y, Chowdhury S, Xu BH, Damiris K and Devalaraju S contributed to the manuscript preparation; All authors contributed to the manuscript revisions, reviewed, and approved the final submitted manuscript.
Institutional review board statement: This retrospective cohort study did not directly involve any patients in the data collection process and the National Inpatient Sample (NIS) database is de-identified and available for the public. Therefore, Institutional Review Board approval was not required.
Conflict-of-interest statement: The authors have no conflicts of interest related to this publication.
Data sharing statement: Technical appendix, statistical code, and dataset available from the corresponding author at Participants gave informed consent for data sharing.
STROBE statement: The authors have read the STROBE Statement, and the manuscript was prepared and revised according to the STROBE Statement.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Nikolaos Pyrsopoulos, FAASLD, AGAF, FACG, MD, PhD, Director, Professor, Department of Medicine, Gastroenterology and Hepatology, Rutgers New Jersey Medical School, 185 S. Orange Avenue, Medical Science Building H-536, Newark, NJ 07101, United States.
Received: June 14, 2021
Peer-review started: June 14, 2021
First decision: July 27, 2021
Revised: August 8, 2021
Accepted: September 19, 2021
Article in press: September 19, 2021
Published online: November 27, 2021
Research background

The ongoing exploration of liver-gut axis has discovered strong association between gut dysbiosis and nonalcoholic fatty liver disease (NAFLD) in both basic science and clinical research. Small-scaled studies have observed that NAFLD is an independent risk factor for Clostridioides difficile infection (CDI).

Research motivation

CDI, as the most common cause of nosocomial diarrhea in developed countries, carries high hospitalization burden. NAFLD, as the leading cause of chronic liver disease, is commonly seen in hospitalized patients with CDI. So far the inpatient outcomes of CDI in the NAFLD population have not been well studied.

Research objectives

The authors aimed to examine the impact of NAFLD on the inpatient outcomes of hospitalized patients with CDI, by comparing the effect of NAFLD with alcoholic liver disease (ALD) and viral liver disease (VLD) individually.

Research methods

This nationwide retrospective cohort study was conducted according to STROBE statement using the National Inpatient Sample database. Inpatient CDI with coexisting NAFLD cases were selected using ICD-9 codes. Multivariate regression analysis was used with adjustment for a large group of possible confounders. Elixhauser Comorbidity Index (ECI) was used for a full description of comorbidity burden.

Research results

CDI with NAFLD was independently associated with lower rates of acute respiratory failure, shorter length of stay and lower hospitalization charges when compared to CDI with VLD and CDI with ALD. However, CDI with NAFLD was associated with a higher rate of intestinal perforation when compared to VLD, and a higher rate of intestinal obstruction when compared to ALD.

Research conclusions

CDI and coexisting NAFLD is associated with favorable overall outcomes, but higher rates of intestinal complications compared to CDI with coexisting ALD and VLD, individually.

Research perspectives

This finding suggests that alteration of gut microbiota may play an important role in the pathogenesis of both CDI and NAFLD. NAFLD associated metabolic syndrome may contribute significantly to the gut dysbiosis and cause increased risk for CDI and its complications. This study provides potential directions for future prospective clinical research to identify the clinical meaningfulness of interactions between gut microbiota, gut immunity and systemic inflammation. The study may open the door for potential microbiota therapeutic targets and manipulation as future treatment options for chronic liver diseases.