qSOFA score not predictive of in-hospital mortality in emergency patients with decompensated liver cirrhosis

Dynamic analysis of acute deterioration in chronic liver disease patients using modified quick sequential organ failure assessment

BACKGROUND/AIMS

Quick sequential organ failure assessment (qSOFA) is believed to identify patients at risk of poor outcomes in those with suspected infection. We aimed to evaluate the ability of modified qSOFA (m-qSOFA) to identify high-risk patients among those with acutely deteriorated chronic liver disease (CLD), especially those with acute-onchronic liver failure (ACLF).

METHODS

We used data from both the Korean Acute-on-Chronic Liver Failure (KACLiF) and the Asian Pacific Association for the Study of the Liver ACLF Research Consortium (AARC) cohorts. qSOFA was modified by replacing the Glasgow Coma Scale with hepatic encephalopathy, and an m-qSOFA ≥2 was considered high.

RESULTS

Patients with high m-qSOFA had a significantly lower 1-month transplant-free survival (TFS) in both cohorts and higher organ failure development in KACLiF than those with low m-qSOFA (Ps<0.05). Subgroup analysis by ACLF showed that patients with high m-qSOFA had lower TFS than those with low m-qSOFA. m-qSOFA was an independent prognostic factor (hazard ratios, HR=2.604, 95% confidence interval, CI 1.353-5.013, P=0.004 in KACLiF and HR=1.904, 95% CI 1.484- 2.442, P<0.001 in AARC). The patients with low m-qSOFA at baseline but high m-qSOFA on day 7 had a significantly lower 1-month TFS than those with high m-qSOFA at baseline but low m-qSOFA on day 7 (52.6% vs. 89.4%, P<0.001 in KACLiF and 26.9% vs. 61.5%, P<0.001 in AARC).

CONCLUSION

Baseline and dynamic changes in m-qSOFA may identify patients with a high risk of developing organ failure and short-term mortality among CLD patients with acute deterioration.

Is the SIRS Criteria a Good Predictor of Blood stream Infection in Cirrhosis? A Single-Center Retrospective Analysis

Introduction

Cirrhosis-associated immune dysfunction (CAID) is a chronic vasodilatory state with hyperdynamic circulation and alterations in thermoregulation that may make patients more susceptible to and mask underlying infection. This study aims to determine whether SIRS criteria are an accurate tool for predicting bloodstream infection (BSI) in cirrhosis.

Methods

In our retrospective chart review, study population included patients with cirrhosis that were 18 years or older. For all study patients, model for end-stage liver disease (MELD) scores and values for each SIRS variable at the time of admission and blood culture data were recorded. Univariable and multivariable logistic regression analysis was performed to identify any associations between dichotomized SIRS variables that fulfill SIRS positivity and BSI.

Results

Significantly more patients without BSI met positivity criteria for WBC counts (30% vs 13% p < .001). In the analysis of the SIRS variables as continuous variables in prediction of BSI, the AUC curves generated were all unsatisfactory with the temperature (36-38°C) and WBC count (4 × 103 to 12 × 103 mcL) at the time of admission having the highest areas under the ROC curve (0.52 and 0.55, respectively). Looking at the SIRS variables dichotomized (according to whether fulfilling SIRS criteria or not) in univariable logistic regression, only WBC counts meeting SIRS criteria were significantly associated with BSI OR 0.37 (0.18-0.77); p = .008, but this was an inverse association. This association was true even in the multivariable model OR 0.38 (0.18-0.80); p = .01.

Conclusion

Our study shows that SIRS criteria are a poor predictor of BSI among patients with cirrhosis.

Cirrhosis Management in the Intensive Care Unit

Patients with cirrhosis frequently require admission to the intensive care unit as complications arise in the course of their disease. These admissions are associated with high short- and long-term morbidity and mortality. Thus, understanding and characterizing complications and unique needs of patients with cirrhosis and acute-on-chronic liver failure helps providers identify appropriate level of care and evidence-based treatments. While there is no widely accepted critical care admission criteria for patients with cirrhosis, the presence of organ failure and primary or nosocomial infections are associated with particularly high in-hospital mortality. Optimal management of patients with cirrhosis in the critical care setting requires a system-based approach that acknowledges deviations from canonical pathophysiology. In this review, we discuss appropriate considerations and evidence-based practices for the general care of patients with cirrhosis and critical illness.

Prognostic accuracy of Quick SOFA in older adults hospitalised with community acquired urinary tract infection

INTRODUCTION

Quick [Sepsis-related] Sequential Organ Failure Assessment (qSOFA) is a prognostic score based on sepsis-3 definition, easy to carry out, whose application has been studied in older adults with sepsis from different sources and respiratory sepsis. However, to date no study has analysed its prognostic accuracy in older adults admitted to hospital with community urinary tract infection.

METHODS

In a prospective study of 282 older adults admitted to hospital with community acquired urinary tract infection, the application of qSOFA to predict hospital mortality was analysed. The predictive capacity of qSOFA for in-hospital mortality was compared with Systemic Inflammatory Response Syndrome score (SIRS) and Sequential Organ Failure Assessment (SOFA), which require laboratory test in order to be calculated.

RESULTS

In a population with a median age of 81 years, where 51.8% were males and 10.6% had septic shock, qSOFA showed sensibility and specificity of 88.46 and 75.78% and area under the receiver operating characteristic curves (AUROC) of 0.810. AUROC for qSOFA was significantly higher than that of SIRS (AUROC 0.597, P = .005) and with no statistical differences with SOFA (AUROC 0.841, P = .635).

CONCLUSION

qSOFA showed a better predictive prognostic accuracy than SIRS and similar to SOFA in older adults admitted to hospital with community acquired urinary tract infection, having the advantage of not requiring laboratory tests.

Lymphocyte-to-monocyte ratio predicts mortality in cirrhotic patients with septic shock

INTRODUCTION

Patients with liver cirrhosis and septic shock have a significantly higher risk of mortality and morbidity compared with non-cirrhotic patients. The peripheral blood lymphocyte-to-monocyte ratio (LMR) can determine the prognosis of cirrhotic patients. Our study aimed to investigate the usefulness of LMR as a predictive marker of mortality risk in cirrhotic patients with septic shock.

METHODS

This single-center, retrospective case-control study included adult patients who visited the emergency department between January 1, 2018 and June 30, 2020 and diagnosed with liver cirrhosis and septic shock. They were divided into survivor and non-survivor groups according to their survival status at the 60-day follow-up. We used a Cox proportional hazards regression model to identify independent factors associated with mortality risk and tested the mortality discriminative ability of those factors using the area under a receiver operating characteristic curve.

RESULTS

A total of 93 patients were eligible for this study. Compared with the patients in the survivor group, those in the non-survivor group had significantly higher Child-Pugh (11 ± 2 vs. 9 ± 2, p < 0.001) and MELD scores (29 ± 6 vs. 22 ± 8, p < 0.001), higher serum international normalized ratio (1.7 vs.1.4, p = 0.03), bilirubin (6.0 vs. 3.3 mg/dL, p = 0.02), lactate (5.4 vs. 2.7 mmol/L, p < 0.01), creatinine (2.2 vs. 1.6 mg/dL, p = 0.04), higher neutrophil-to-lymphocyte ratio (13.0 vs. 10.3, p = 0.02), and lower LMR (1.1 vs. 2.3, p < 0.01). The LMR (adjusted hazard ratio [aHR] = 1.54, p = 0.01) and lactate (aHR = 1.03, p < 0.01) were identified as independent predictive factors for mortality in the multivariate regression model. Furthermore, LMR (area under curve [AUC]: 0.87) revealed a superior discrimination ability in mortality prediction compared with the Child-Pugh (AUC: 0.72) and MELD (AUC: 0.76) scores.

CONCLUSIONS

The LMR can be used to predict mortality risk in cirrhotic patients with septic shock.

Update on diagnosis and management of sepsis in cirrhosis: Current advances

Sepsis and septic shock are catastrophic disease entities that portend high mortality in patients with cirrhosis. In cirrhosis, hemodynamic perturbations, immune dysregulation, and persistent systemic inflammation with altered gut microbiota in the background of portal hypertension enhance the risk of infections and resistance to antimicrobials. Patients with cirrhosis develop recurrent life-threatening infections that progress to multiple organ failure. The definition, pathophysiology, and treatment options for sepsis have been ever evolving. In this exhaustive review, we discuss novel advances in the understanding of sepsis, describe current and future biomarkers and scoring systems for sepsis, and delineate newer modalities and adjuvant therapies for the treatment of sepsis from existing literature to extrapolate the same concerning the management of sepsis in cirrhosis. We also provide insights into the role of gut microbiota in initiation and progression of sepsis and finally, propose a treatment algorithm for management of sepsis in patients with cirrhosis.

[Procalcitonin in the intensive care unit : Differential diagnostic and differential therapeutic possibilities]

Prokalzitonin (PCT) wird bei systemischen Inflammationszuständen IL6-, IL8- und TNF-α-vermittelt in multiplen Organen und Strukturen des Körpers gebildet. Dabei werden insbesondere bei der Sepsis deutlich erhöhte Werte gemessen. Die Höhe des PCT korreliert dabei gut mit der Krankheitsschwere, ein signifikanter Abfall unter Therapie mit der Prognose. In der differenzialdiagnostischen Abklärung kann die PCT-Bestimmung zwischen bakteriellen und viralen Infektionen unterscheiden. Nichtinfektiösbedingte inflammatorische Reaktionen können jedoch moderat erhöhte PCT-Werte zeigen. Cut-off-Werte sind abhängig von der renalen und hepatischen Funktion. Ein Therapiealgorithmus zur Antibiotikadauer mit PCT-Verlaufsbestimmungen kann den Antibiotikagebrauch reduzieren. In dieser Arbeit sollen die differenzialdiagnostischen und differenzialtherapeutischen Möglichkeiten einer Prokalzitoninbestimmung bei kritisch kranken Patienten erörtert werden.