Ashok Choudhury1, Manoj Kumar1, Barjesh C Sharma1, Rakhi Maiwall1, Viniyendra Pamecha2, Richard Moreau3,4, Yogesh K Chawla5, Ajay Duseja5, Mamun Mahtab6, Salimur Rahman6, Saeed S Hamid7, Amna S Butt7, Wasim Jafri7, Seok Siam Tan8, Harshad Devarbhavi9, Deepak Amarapurkar10, Qin Ning11, C E Eapen12, Ashish Goel12, Dong J Kim13, Hasmik Ghazinyan14, Gamal Shiha15, Guan H Lee16, Zaigham Abbas17, Diana A Payawal18, A Kadir Dokmeci19, Man-Fung Yuen20, Laurentius A Lesmana21, Ajit Sood22, Albert Chan23, George K Lau24, Ji Dong Jia25, Zhongping Duan26, Chen Yu27, Osamu Yokosuka27, Priyanka Jain1, Ajeet S Bhadoria1, Guresh Kumar1, Shiv K Sarin1. 1. Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences, New Delhi, India. 2. Department of Hepatobiliary Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India. 3. The National (French) Institute of Health (INSERM), Paris, France. 4. UMR_S 1149, Labex INFLAMEX, Université Paris Diderot Paris 7, Paris, France. 5. Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India. 6. Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh. 7. Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan. 8. Department of Gastroenterology and Hepatology, Selayang Hospital, Kepong, Malaysia. 9. Department of Gastroenterology and Hepatology, St John Medical College, Bangalore, India. 10. Department of Gastroenterology and Hepatology, Bombay Hospital and Medical Research Centre, Mumbai, India. 11. Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China. 12. Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India. 13. Center for Liver and Digestive Diseases, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Gangwon-Do, Korea. 14. Department of Hepatology, Nork Clinical Hospital of Infectious Diseases, Yerevan, Armenia. 15. Department of Internal Medicine, Egyptian Liver Research Institute and Hospital, Cairo, Egypt. 16. Department of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore. 17. Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan. 18. Department of Hepatology, Cardinal Santos Medical Center, Manila, Philippines. 19. Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey. 20. Department of Medicine, The University of Hong Kong, Hong Kong. 21. Division of Hepatology, University of Indonesia, Jakarta, Indonesia. 22. Department of Gastroenterology, Dayanand Medical College, Ludhiana, India. 23. Division of Hepatobiliary and Pancreatic Surgery, and Liver Transplantation, Department of Surgery, The University of Hong Kong, Hong Kong. 24. The Institute of Translational Hepatology, Beijing, China. 25. Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China. 26. Beijing Youan Hospital, Capital Medical University, Beijing, China. 27. Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan.
Abstract
BACKGROUND AND AIM: Systemic inflammatory response syndrome (SIRS) is an early marker of sepsis and ongoing inflammation and has been reported in large proportion of acute-on-chronic liver failure (ACLF) patients. Whether sepsis is the cause or the result of liver failure is unclear and is vital to know. To address this, the study investigated the course and outcome of ACLF patients without SIRS/sepsis. METHODS: Consecutive ACLF patients were monitored for the development of SIRS/sepsis and associated complications and followed till 90 days, liver transplant or death. RESULTS: Of 561 patients, 201 (35.8%) had no SIRS and 360 (64.2%) had SIRS with or without infection. New onset SIRS and sepsis developed in 74.6% and 8% respectively in a median of 7 (range 4-15) days, at a rate of 11% per day. The cumulative incidence of new SIRS was 29%, 92.8%, and 100% by days 4, 7, and 15. Liver failure, that is, bilirubin > 12 mg/dL (odds ratio [OR] = 2.5 [95% confidence interval {CI} = 1.05-6.19], P = 0.04) at days 0 and 4, and renal failure at day 4 (OR = 6.74 [95%CI = 1.50-13.29], P = 0.01), independently predicted new onset SIRS. Absence of SIRS in the first week was associated with reduced incidence of organ failure (20% vs 39.4%, P = 0.003), as was the 28-day (17.6% vs 36%, P = 0.02) and 90-day (27.5% vs 51%,P = 0.002) mortality. The 90-day mortality was 61.6% in the total cohort and that for those having no SIRS and SIRS at presentation were 42.8% and 65%, respectively (P < 0.001). CONCLUSION: Liver failure predicts the development of SIRS. New onset SIRS in the first week is an important determinant of early sepsis, organ failure, and survival. Prompt interventions in this 'golden window' before development of sepsis may improve the outcome of ACLF.
BACKGROUND AND AIM: Systemic inflammatory response syndrome (SIRS) is an early marker of sepsis and ongoing inflammation and has been reported in large proportion of acute-on-chronic liver failure (ACLF) patients. Whether sepsis is the cause or the result of liver failure is unclear and is vital to know. To address this, the study investigated the course and outcome of ACLF patients without SIRS/sepsis. METHODS: Consecutive ACLF patients were monitored for the development of SIRS/sepsis and associated complications and followed till 90 days, liver transplant or death. RESULTS: Of 561 patients, 201 (35.8%) had no SIRS and 360 (64.2%) had SIRS with or without infection. New onset SIRS and sepsis developed in 74.6% and 8% respectively in a median of 7 (range 4-15) days, at a rate of 11% per day. The cumulative incidence of new SIRS was 29%, 92.8%, and 100% by days 4, 7, and 15. Liver failure, that is, bilirubin > 12 mg/dL (odds ratio [OR] = 2.5 [95% confidence interval {CI} = 1.05-6.19], P = 0.04) at days 0 and 4, and renal failure at day 4 (OR = 6.74 [95%CI = 1.50-13.29], P = 0.01), independently predicted new onset SIRS. Absence of SIRS in the first week was associated with reduced incidence of organ failure (20% vs 39.4%, P = 0.003), as was the 28-day (17.6% vs 36%, P = 0.02) and 90-day (27.5% vs 51%,P = 0.002) mortality. The 90-day mortality was 61.6% in the total cohort and that for those having no SIRS and SIRS at presentation were 42.8% and 65%, respectively (P < 0.001). CONCLUSION:Liver failure predicts the development of SIRS. New onset SIRS in the first week is an important determinant of early sepsis, organ failure, and survival. Prompt interventions in this 'golden window' before development of sepsis may improve the outcome of ACLF.
Authors: Jörn Grensemann; David Busse; Christina König; Kevin Roedl; Walter Jäger; Dominik Jarczak; Stefanie Iwersen-Bergmann; Carolin Manthey; Stefan Kluge; Charlotte Kloft; Valentin Fuhrmann Journal: Ann Intensive Care Date: 2020-04-22 Impact factor: 6.925