title: Risk factors and outcome in patients with primary sclerosing cholangitis with persistent biliary candidiasis.
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.
authors.forename: Christian
authors.initials: C
authors.lastname: Rupp
authors.forename: Konrad Alexander
authors.initials: KA
authors.lastname: Bode
authors.forename: Fadi
authors.initials: F
authors.lastname: Chahoud
authors.forename: Andreas
authors.initials: A
authors.lastname: Wannhoff
authors.forename: Kilian
authors.initials: K
authors.lastname: Friedrich
authors.forename: Karl-Heinz
authors.initials: KH
authors.lastname: Weiss
authors.forename: Peter
authors.initials: P
authors.lastname: Sauer
authors.forename: Wolfgang
authors.initials: W
authors.lastname: Stremmel
authors.affiliation: Department of Internal Medicine IV, University Hospital of Heidelberg, Im Neuenheimer Feld 410, Heidelberg, 69120, Germany. Daniel.gotthardt@med.uni-heidelberg.de.
authors.forename: Daniel Nils
authors.initials: DN
authors.lastname: Gotthardt
mesh_terms: D000328:Adult; D001652:Bile Ducts / Q000382:microbiology; D002177:Candidiasis / Q000382:microbiology* / Q000401:mortality / Q000628:therapy; D015209:Cholangitis, Sclerosing / Q000382:microbiology* / Q000401:mortality / Q000628:therapy; D018572:Disease-Free Survival; D005260:Female; D006801:Humans; D015994:Incidence; D016031:Liver Transplantation; D008297:Male; D015999:Multivariate Analysis; D012189:Retrospective Studies; D012307:Risk Factors; D016896:Treatment Outcome