Systemic Inflammatory Response Syndrome in Acute on Chronic Liver Failure- Relevance of 'Golden Window'- a Prospective Study

A Choudhury, Institute of Liver and Biliary Sciences, New Delhi, India.
M Kumar, , Institute of Liver and Biliary Sciences, New Delhi, India.
B C. Sharma, Inserm, U1149, Centre de recherche sur l'Inflammation (CRI), Paris; UMR_S 1149, Labex INFLAMEX, Université Paris Diderot Paris 7, Paris, France.
R Maiwall, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
V Pamecha, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.
R Moreau, Aga Khan University
Y K. Chawla,, Selayang Hospital, Kepong, Malaysia.
A Duseja,, Bombay Hospital and Medical Research Centre, Mumbai, India.
M Mahtab, Bombay Hospital and Medical Research Centre, Mumbai, India.
S Rahman,, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
S S. Hamid,, Christian Medical College, Vellore, India.
A s. Butt,, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Gangwon-Do, Republic of Korea.
w Jafri, Egyptian Liver Research Institute and Hospital, Cairo, Egypt.
S S. Tan, National University Health System, Singapore, Singapore.
H Devarbhavi, National University Health System, Singapore, Singapore.
D Amarapurkar, Sindh Institute of Urology and Transplantation, Karachi, Pakistan.
Q Ning,, Cardinal Santos Medical Center, Manila, Philippines.
C E. Eapen,, Ankara University School of Medicine, Ankara, Turkey.
Ashish Goel,, The University of Hong Kong, Hong Kong, China.
D J. Kim,, University of Indonesia, Jakarta, Indonesia.
H Ghazinian, , Dayanand Medical College, Ludhiana, India.
G SHIHA, , The University of Hong Kong, Hong Kong, China.
G H. Lee,, The Institute of Translational Hepatology, Beijing, China.
Z Abbas, Capital Medical University, Beijing, China.
D A. Payawal, Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
A K. Dokmeci, Graduate School of Medicine, Chiba University, Chiba, Japan.
M F. Yuen,

Abstract

BACKGROUND: SIRS is an early marker of sepsis and ongoing inflammationand has been reported in large proportion of ACLF patients. Whether sepsis is the cause or the result of liver failure is unclear and is vital to know. To address this, we 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 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 day 4,7 and 15. Liver failure i.e., bilirubin >12 mg/dl, [(OR = 2.5(95%CI = 1.05-6.19), p = 0.04] at day 0 and 4, 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 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).

CONCLUSIONS: Liver failure predicts the development of SIRS. New onset SIRS in first week is an important determinant of early sepsis, organ failure and survival. Prompt interventions in this 'Golden window' prior to development of sepsis, may improve outcome of ACLF.