Prevalence, predictors, and outcomes of esophageal candidiasis in cirrhosis: an observational study with systematic review and meta-analysis (CANDID-VIEW)

Abstract Background Gastrointestinal candidiasis is often neglected and potentially serious infection in cirrhosis patients. Therefore, we evaluated the prevalence, risk factors, and outcomes of esophageal candidiasis (EC) in cirrhotics and did a systematic review to summarize EC’s available evidence in cirrhosis. Methods Consecutive patients with cirrhosis posted for esophago-gastro-duodenoscopy (EGD) at a tertiary-care institute were screened for EC (cases) between January-2019 and March-2020. EC was diagnosed on EGD-findings and/or brush cytology. Controls (without EC) were recruited randomly, and EC's risk factors and outcomes were compared between cases and controls. Four-electronic-databases were searched for studies describing EC in cirrhosis. Prevalence-estimates of EC were pooled on random-effects meta-analysis, and heterogeneity was assessed by I2. A checklist for prevalence-studies was used to evaluate the risk of bias in studies. EC was diagnosed in 100 out of 2762 cirrhosis patients (3.6%). Patients with EC had a higher MELD (12.4 vs. 11.2; p=0.007), acute-on-chronic liver failure (ACLF) (26% vs. 10%; p=0.003) and concomitant bacterial-infections (24% vs. 7%; p=0.001); as compared to controls. A multivariable model, including recent alcohol binge, hepatocellular carcinoma (HCC), UGI-bleed, ACLF, diabetes, and MELD, predicted EC's development in cirrhosis with excellent discrimination (C-index:0.918). Six-percent of cases developed the invasive disease and worsened with multi-organ failures, and four patients with EC died on follow-up. Out of 236 articles identified, EC's pooled-prevalence from 8 studies (all with low-risk of bias) was 2.1% (95% CI: 0.8-5.8). Risk factors and outcomes of EC in cirrhosis were not reported in the literature. Conclusions EC is not a rare infection in cirrhosis patients, and it may predispose to invasive candidiasis and untimely deaths. Alcohol binge, HCC, UGI-bleed, ACLF, diabetes, and higher MELD are the independent predictors of EC in cirrhosis. At-risk cirrhotics or those with deglutition-symptoms should be rapidly screened and treated for EC.