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Acute liver failure predicts onset of systemic inflammation response syndrome

By defining the onset of systemic inflammation response system after acute-on-chronic liver failure, researchers suggest they can set earlier interventions and prevent early sepsis and organ failure, improving overall outcomes.

“The chance of reversibility of [acute-on chronic liver failure (ACLF)] is likely to decrease once the extra-hepatic organ failure(s) sets-in. Even the suitability for liver transplantation decreases in the presence of extra-hepatic organ failure,” the researchers wrote. “It is therefore worthwhile to identify the short interim period between liver failure and the onset of extra-hepatic organ failure and intervene during this potential therapeutic ‘golden window.’ Scenarios where extra-hepatic organ dysfunction precedes liver failure or sepsis precipitates liver failure, indeed may have a different natural course and should form a different disease sub-group.”

Between April 2009 and April 2015, the researchers enrolled 561 patients diagnosed with acute- on chronic liver failure and divided them into two cohorts: patients with present systemic inflammation response (SIRS) of at least two components (n = 360) and patients with no SIRS or sepsis (n = 201). Sepsis was confirmed in 143 of the SIRS group. The average patient age was 44.5 years and 89.2% were men.

In the SIRS-absent group, new onset SIRS was seen in 49 patients at day 4 following liver failure diagnosis, in 101 patients at day 7 and in 5 patients at day 15. Sepsis developed in eight of these patients at day 4, in eight at day 7 and in three at day 15.

The 150 patients who developed SIRS by day 7 had a higher incidence of organ failure (P = .003) and had higher 28-day (P = .02) and 90-day (P = .03) mortality. The researchers also found that the presence of liver failure (OR = 2.5; 95% CI, 1.05-6.19), new onset acute kidney injury (OR = 6.74; 95% CI, 1.5-13.29) or the presence of liver failure at day 4 (OR = 2.3; 95% CI, 0.98-5.3) independently predicted new onset SIRS in the first week.

Persistence of SIRS until day 4 resulted in greater rates of liver failure (74.9% vs. 42.5%; P = .01), coagulation failure (44.2% vs. 18.8%; P = .001), renal failure (30.4% vs. 8.8%; P = .001) and circulatory failure (6.5% vs. 0.6%; P = .01) compared with patients who had resolution of SIRS. In a similar comparison, the persistence of SIRS until day 7 resulted in greater rates of liver failure (77.6% vs. 56.3; P = .03), coagulation failure (35.7% vs. 15.6%; P = .01), renal failure (33.6% vs. 15.6%; P = .02) and a high 90-day mortality (73.8% vs. 50%; P = .001)

In the SIRS-absent group, mortality rates were 11.4% at day 7, 33.8% at day 28 and 42.8% at day 90. In the SIRS group, morality rates were 28.6% at day 7, 49.3% at day 28 and 65% at day 90.

“The present study gathered enough evidence to conclude that the ‘first week of hospitalization’ in ACLF patients should be considered as the ‘golden window’ period,” the researchers wrote. “The first week of diagnosis is the crucial period. Early detection of SIRS and consideration of appropriate strategies like escalation of antibiotics, prioritization for definitive therapy (ie, liver transplant) prior to onset of sepsis and multi-organ failure is needed.” – by Talitha Bennett

Disclosure : The researchers report no relevant financial disclosures.