Systemic inflammatory response syndrome in acute-on-chronic liver failure: Relevance of 'golden window': A prospective study

Choudhury A 1 , Kumar M 1 , Sharma BC 1 , Maiwall R 1 , Pamecha V 2 , Moreau R 3 Show all authors , Chawla YK 4 , Duseja A 4 , Mahtab M 5 , Rahman S 5 , Hamid SS 6 , Butt AS 6 , Jafri W 6 , Tan SS 7 , Devarbhavi H 8 , Amarapurkar D 9 , Ning Q 10 , Eapen CE 11 , Goel A 11 , Kim DJ 12 , Ghazinyan H 13 , Shiha G 14 , Lee GH 15 , Abbas Z 16 , Payawal DA 17 , Dokmeci AK 18 , Yuen MF 19 , Lesmana LA 20 , Sood A 21 , Chan A 22 , Lau GK 23 , Jia JD 24 , Duan Z 25 , Yu C 26 , Yokosuka O 26 , Jain P 1 , Bhadoria AS 1 , Kumar G 1 , Sarin SK 1 , APASL ACLF working party

Affiliations 

  • 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 Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
  • 5 Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
  • 6 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
  • 7 Department of Gastroenterology and Hepatology, Selayang Hospital, Kepong, Malaysia
  • 8 Department of Gastroenterology and Hepatology, St John Medical College, Bangalore, India
  • 9 Department of Gastroenterology and Hepatology, Bombay Hospital and Medical Research Centre, Mumbai, India
  • 10 Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
  • 11 Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
  • 12 Center for Liver and Digestive Diseases, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Gangwon-Do, Korea
  • 13 Department of Hepatology, Nork Clinical Hospital of Infectious Diseases, Yerevan, Armenia
  • 14 Department of Internal Medicine, Egyptian Liver Research Institute and Hospital, Cairo, Egypt
  • 15 Department of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore
  • 16 Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan
  • 17 Department of Hepatology, Cardinal Santos Medical Center, Manila, Philippines
  • 18 Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
  • 19 Department of Medicine, The University of Hong Kong, Hong Kong
  • 20 Division of Hepatology, University of Indonesia, Jakarta, Indonesia
  • 21 Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
  • 22 Division of Hepatobiliary and Pancreatic Surgery, and Liver Transplantation, Department of Surgery, The University of Hong Kong, Hong Kong
  • 23 The Institute of Translational Hepatology, Beijing, China
  • 24 Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
  • 25 Beijing Youan Hospital, Capital Medical University, Beijing, China
  • 26 Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan
J Gastroenterol Hepatol, 2017 Dec;32(12):1989-1997.
PMID: 28374414 DOI: 10.1111/jgh.13799

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 

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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