Systemic Inflammatory Response Syndrome in Patients Hospitalized for Acute Decompensation of Cirrhosis.

Background: Although recently challenged, systemic inflammatory response syndrome (SIRS) criteria are still commonly used in daily practice to define sepsis. However, several factors in liver cirrhosis may negatively impact its prognostic ability. Goals. To investigate the factors associated with the presence of SIRS, the characteristics of SIRS related to infection, and its prognostic value among patients hospitalized for acute decompensation of cirrhosis. Study. In this cohort study from two tertiary hospitals, 543 patients were followed up, up to 90 days. Data collection, including the prognostic models, was within 48 hours of admission. Results: SIRS was present in 42.7% of the sample and was independently associated with upper gastrointestinal bleeding (UGB), ACLF, infection, and negatively related to beta-blockers. SIRS was associated with mortality in univariate analysis, but not in multiple Cox regression analysis. The Kaplan-Meier survival probability of patients without SIRS was 73.0% and for those with SIRS was 64.7%. The presence of SIRS was not significantly associated with mortality when considering patients with or without infection, separately. Infection in SIRS patients was independently associated with Child-Pugh C and inversely related to UGB. Among subjects with SIRS, mortality was independently related to the presence of infection, ACLF, and Child-Pugh C. Conclusions: SIRS was common in hospitalized patients with cirrhosis and was of no prognostic value, even in the presence of infection.

Serial assessment of hepatic encephalopathy in patients hospitalised for acute decompensation of cirrhosis.

INTRODUCTION AND AIM: Hepatic encephalopathy (HE) is a frequent complication of cirrhosis, but the clinical and prognostic significance of the progression of mental status in hospitalised cirrhotics is unknown. We aimed to investigate the prognostic significance of serial evaluation of HE in patients hospitalised for acute decompensation (AD) of cirrhosis. MATERIALS AND METHODS: Patients (n=293) were evaluated for HE (West-Haven criteria) at admission and at day-3 and classified in two groups: (1) Absent or improved HE: HE absent at admission and at day-3, or any improvement at day-3; (2) Unfavourable progression: Development of HE or HE present at admission and stable/worse at day-3. RESULTS: Unfavourable progression of HE was observed in 31% of patients and it was independently associated with previous HE, Child-Pugh C and acute-on-chronic liver failure (ACLF). MELD score and unfavourable progression of HE were independently associated with 90-day mortality. The 90-day Kaplan-Meier survival probability was 91% in patients with MELD<18 and absent or improved HE and only 31% in subjects with both MELD≥18 and unfavourable progression of HE. Unfavourable progression of HE was also related to lower survival in patients with or without ACLF. Worsening of GCS at day-3 was observed in 11% of the sample and was related with significantly high mortality (69% vs. 27%, P<0.001). CONCLUSION: Among cirrhotics hospitalised for AD, unfavourable progression of HE was associated with high short-term mortality and therefore can be used for prognostication and to individualise clinical care.

Applicability of Sepsis-3 criteria and quick Sequential Organ Failure Assessment in patients with cirrhosis hospitalised for bacterial infections.

BACKGROUND & AIMS: An algorithm including Sepsis-3 criteria and quick Sequential Organ Failure Assessment (qSOFA) was recently proposed to predict severity of infection in cirrhosis. However, its applicability among patients without a baseline SOFA available for Sepsis-3 definition is unknown. We sought to investigate the applicability and prognostic value of qSOFA and Sepsis-3 criteria in patients with cirrhosis hospitalised for bacterial infections, without pre-hospitalisation SOFA. METHODS: In this cohort study, 164 patients were followed up to 30 days. Data collection, including the prognostic models, was performed at admission and at day-3. RESULTS: All patients fulfilled Sepsis-3 criteria (admission SOFA ≥ 2) and, therefore, admission Sepsis-3 was not included in further analysis. Admission qSOFA was an independent predictor of survival (HR = 2.271, P = 0.015). For patients initially classified as high risk by qSOFA, Chronic Liver Failure - Sequential Organ Failure Assessment (CLIF-SOFA) was the only prognostic predictor. Among patients initially classified as low risk by qSOFA, the following parameters evaluated at day-3 were independent predictors of survival: qSOFA, acute-on-chronic liver failure, and Child-Pugh classification. Although not independently related to survival, Sepsis-3 criteria at day-3 was associated with lower 30-day survival in Kaplan-Meier analysis (66% vs 85%, P = 0.008). However, prognosis was better predicted by day-3 qSOFA, with 30-day Kaplan-Meier survival probability of 88% when qSOFA < 2 and 24% among those with qSOFA ≥ 2. CONCLUSION: Sepsis-3 criteria evaluated at admission are very limited in infected patients with cirrhosis without baseline SOFA. qSOFA was independently related to survival and appears to be a valuable tool for determining severity of infection and to follow patients initially classified as low risk.

Liver dysfunction and fibrosis as predictors of biochemical response to autoimmune hepatitis treatment.

BACKGROUND: Autoimmune hepatitis (AIH) is a disease that presents itself in various forms, ranging from aminotransferase asymptomatic alteration, acute hepatitis to decompensated cirrhosis. Few studies have evaluated the predictive criteria as a response to treatment. METHODS: A cross-sectional analytical study examined patients with AIH who were visited in the hepatology clinic of a university hospital between January 2013 and July 2015. RESULTS: A total of 36 patients were included (44.7 ± 14.3 years, 22.2% male, and 19.2% of patients presented with liver failure). Patients with significant fibrosis had lower mean aminotransferases and bilirubins and higher mean prothrombin activity (PA) than those with insignificant fibrosis. Most patients (94.5%) underwent treatment with azathioprine and prednisone. In a comparison between individuals who exhibited biochemical response (ALT and AST < 55 U/L in the sixth month of treatment) and those without biochemical response, it was observed that those with biochemical response presented minor proportion of patients with significant fibrosis, and these patients had a higher proportion of liver failure in initial presentation and lower mean PA. Furthermore, it was observed that the lower the PT on admission was, the lower ALT levels (r = 0.682, P = 0.020) and AST (r = 0.431, P = 0.040) in the sixth month of treatment were. CONCLUSIONS: Individuals with liver dysfunction and elevated aminotransferases show insignificant fibrosis histologically. AIH patients who initially present liver failure and insignificant fibrosis are more likely to develop biochemical response to treatment.

¿Cuál es el perfil de los pacientes en espera de nuevos tratamientos para la hepatitis C? / What is the Profile of Patients Waiting for New Hepatitis C Treatments?

Introducción: hasta hace poco, el tratamiento estándar de oro para la hepatitis C eran los interferones pegilados (Peg-IFN) en combinación con la ribavirina (RBV). Con la llegada de nuevos fármacos, se propuso evaluar los resultados del tratamiento y a los pacientes en espera de la nueva terapia. Materiales y métodos: este estudio analítico transversal evaluó el resultado del tratamiento en individuos con hepatitis C crónica, y luego comparó a individuos que tienen experiencia en no responder al tratamiento basado en interferón (IFN) con individuos sin experiencia de tratamiento previo. Resultados: el estudio incluyó 192 individuos. Entre 87 pacientes sometidos a tratamiento, se observaron bajas tasas de respuesta viral sostenida (RVS). La comparación de los 105 pacientes no tratados previamente y los 87 que habían recibido tratamiento con IFN previamente evidenció que entre los pacientes en espera de nuevas terapias, los individuos sin tratamiento previo presentaron mayor proporción de genotipo 1 (68% frente a 49%; p = 0,028), menores niveles de ALT (91,1 ± 73,0 frente a 126,0 ± 73,40 U/L; p = 017), de AST (70,1 ± 51,3 frente a 89,7 ± 47,40 U/L; p = 050), de GGT (85,3 ± 85,1 frente a 148,4 ± 123,9 U/L; p = 0,007) y menor proporción de fibrosis significativa (24,3 frente a 83,3; p <0,001). Conclusiones: las tasas de RVS fueron bajas. La mayoría de posibles candidatos para el tratamiento por VHC no lo han tenido y son de genótipo-1 con histología leve.

Introduction: Until recently, treatment with a combination of pegylated interferons (Peg-IFN) and ribavirin (RBV) was the gold standard treatment for hepatitis C. In anticipation of the arrival of new drugs, we evaluate current treatment outcomes and patients waiting for the new therapy. Materials and Methods: This cross-sectional analytical study evaluated treatment outcomes among chronic hepatitis C patients, and then compared chronic non-responders and treatment naïve patients who were given interferon based-treatment. Results: The study included 192 individuals among whom were 87 patients who received treatment. Among treated patients, we observed low rates of sustained viral response. A comparison of 105 treatment-naïve patients and 87 who had previously received IFN treatment showed that among patients waiting for new therapies, naïve individuals presented a higher proportion of genotype 1 (68% vs. 49%; p = 0.028) than did previously treated patients, lower ALT (91.1 ± 73.0 vs. 126.0 ± 73.40 U/L; p =017), lower AST (70.1 ± 51.3 vs. 89.7 ± 47.40 U/L; p = 050), lower GGT (85.3 ± 85.1 vs. 148.4 ± 123.9 U/L; p = 0.007) levels and a lower proportion of significant fibrosis (24.3% vs. 83.3%; p < 0.001). Conclusions: SVR rates were low. Among potential candidates for HCV treatment, the majority are naïve, genotype-1 with mild histology.

Enterococcus casseliflavus and Enterococcus gallinarum as causative agents of spontaneous bacterial peritonitis.

Infection by multidrug resistant bacteria is arousing as a relevant issue among hospitalized subjects and is of particular interest in patients with cirrhosis given the frequent use of broad spectrum antibiotics and their altered immune response. We report the first case report of spontaneous bacterial peritonitis (SBP) caused by Enterococcus casseliflavus and the sixth case of SBP caused by Enterococcus gallinarum.