title: Impact of fulminant hepatic failure in C-reactive protein?
abstract: BACKGROUND
  Fulminant hepatic failure (FHF) refers to the rapid development of severe acute liver injury with impaired synthetic function, coagulopathy, and encephalopathy in a person who previously had a normal liver or had a well-compensated liver disease. It is a rare complication in critically ill patients and carries a very bad prognosis. Serum C-reactive protein (CRP), a useful marker of infection, is produced exclusively by the liver.
  
  
  OBJECTIVE
  The aim of this study was to assess CRP concentrations in patients with FHF.
  
  
  METHODS
  We prospectively identified patients with sepsis and FHF treated at the intensive care unit (ICU). Data collected included admission diagnosis, medical history, systemic inflammatory response syndrome criteria, Acute Physiologic and Chronic Health Evaluation II, and Sequential Organ Failure Assessment scores. C-reactive protein and white cell count were measured at admission and then daily until ICU discharge.
  
  
  RESULTS
  We included 7 patients with FHF and sepsis. Six patients died with severe multiple organ failure. Six patients were already admitted with FHF, with the remaining one being diagnosed at the 26th day of ICU stay. All patients present severe coagulopathy. In all septic patients, despite clinical deterioration, CRP levels were markedly decreased sometimes reaching undetectable levels.
  
  
  CONCLUSIONS
  In septic patients with FHF, CRP is more a marker of severe liver dysfunction and should not be used as a marker of infection. As a result, in a patient admitted with a very high suspicion of infection and an abnormally low CRP concentration or with a marked CRP decline despite persistent septic shock, severe hepatic failure should be ruled out.
authors.affiliation: Medical Intensive Care Unit, Faculty of Medical Sciences, São Francisco Xavier Hospital, New University of Lisbon, Estrada do Forte do Alto do Duque, 1449-005 Lisboa. joanapssilvestre@gmail.com
authors.forename: Joana Pedro da Silva
authors.initials: JP
authors.lastname: Silvestre
authors.forename: Luis Miguel da Cruz
authors.initials: LM
authors.lastname: Coelho
authors.forename: Pedro Manuel Sarmento Rodrigues
authors.initials: PM
authors.lastname: Póvoa
mesh_terms: D000328:Adult; D000368:Aged; D015415:Biomarkers / Q000097:blood; D002097:C-Reactive Protein / Q000032:analysis*; D003422:Critical Care; D005260:Female; D006801:Humans; D007362:Intensive Care Units; D017114:Liver Failure, Acute / Q000097:blood*; D008297:Male; D008875:Middle Aged; D011446:Prospective Studies; D018805:Sepsis / Q000097:blood*; D012720:Severity of Illness Index; D012772:Shock, Septic / Q000097:blood; D055815:Young Adult
chemical_list: D015415:Biomarkers; D002097:C-Reactive Protein