title: Systemic inflammatory response syndrome in acute-on-chronic liver failure: Relevance of 'golden window': A prospective study.
abstract: OBJECTIVE
  Systemic inflammatory response syndrome (SIRS) is an early marker of sepsis and ongoing inflammation and has been reported in large proportion of acute-on-chronic liver failure (ACLF) patients. Whether sepsis is the cause or the result of liver failure is unclear and is vital to know. To address this, the study 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 of 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 days 4, 7, and 15. Liver failure, that is, bilirubin > 12 mg/dL (odds ratio [OR] = 2.5 [95% confidence interval {CI} = 1.05-6.19], P = 0.04) at days 0 and 4, and 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 the 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 the first week is an important determinant of early sepsis, organ failure, and survival. Prompt interventions in this 'golden window' before development of sepsis may improve the outcome of ACLF.
authors.affiliation: Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Ashok
authors.initials: A
authors.lastname: Choudhury
authors.affiliation: Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Manoj
authors.initials: M
authors.lastname: Kumar
authors.affiliation: Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Barjesh C
authors.initials: BC
authors.lastname: Sharma
authors.affiliation: Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Rakhi
authors.initials: R
authors.lastname: Maiwall
authors.affiliation: Department of Hepatobiliary Surgery and Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Viniyendra
authors.initials: V
authors.lastname: Pamecha
authors.affiliation: The National (French) Institute of Health (INSERM), Paris, France.|UMR_S 1149, Labex INFLAMEX, Université Paris Diderot Paris 7, Paris, France.
authors.forename: Richard
authors.initials: R
authors.lastname: Moreau
authors.affiliation: Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Yogesh K
authors.initials: YK
authors.lastname: Chawla
authors.affiliation: Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Ajay
authors.initials: A
authors.lastname: Duseja
authors.affiliation: Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.
authors.forename: Mamun
authors.initials: M
authors.lastname: Mahtab
authors.affiliation: Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.
authors.forename: Salimur
authors.initials: S
authors.lastname: Rahman
authors.affiliation: Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Saeed S
authors.initials: SS
authors.lastname: Hamid
authors.affiliation: Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Amna S
authors.initials: AS
authors.lastname: Butt
authors.affiliation: Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
authors.forename: Wasim
authors.initials: W
authors.lastname: Jafri
authors.affiliation: Department of Gastroenterology and Hepatology, Selayang Hospital, Kepong, Malaysia.
authors.forename: Seok Siam
authors.initials: SS
authors.lastname: Tan
authors.affiliation: Department of Gastroenterology and Hepatology, St John Medical College, Bangalore, India.
authors.forename: Harshad
authors.initials: H
authors.lastname: Devarbhavi
authors.affiliation: Department of Gastroenterology and Hepatology, Bombay Hospital and Medical Research Centre, Mumbai, India.
authors.forename: Deepak
authors.initials: D
authors.lastname: Amarapurkar
authors.affiliation: Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
authors.forename: Qin
authors.initials: Q
authors.lastname: Ning
authors.affiliation: Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India.
authors.forename: C E
authors.initials: CE
authors.lastname: Eapen
authors.affiliation: Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India.
authors.forename: Ashish
authors.initials: A
authors.lastname: Goel
authors.affiliation: Center for Liver and Digestive Diseases, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Gangwon-Do, Korea.
authors.forename: Dong J
authors.initials: DJ
authors.lastname: Kim
authors.affiliation: Department of Hepatology, Nork Clinical Hospital of Infectious Diseases, Yerevan, Armenia.
authors.forename: Hasmik
authors.initials: H
authors.lastname: Ghazinyan
authors.affiliation: Department of Internal Medicine, Egyptian Liver Research Institute and Hospital, Cairo, Egypt.
authors.forename: Gamal
authors.initials: G
authors.lastname: Shiha
authors.affiliation: Department of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore.
authors.forename: Guan H
authors.initials: GH
authors.lastname: Lee
authors.affiliation: Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan.
authors.forename: Zaigham
authors.initials: Z
authors.lastname: Abbas
authors.affiliation: Department of Hepatology, Cardinal Santos Medical Center, Manila, Philippines.
authors.forename: Diana A
authors.initials: DA
authors.lastname: Payawal
authors.affiliation: Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey.
authors.forename: A Kadir
authors.initials: AK
authors.lastname: Dokmeci
authors.affiliation: Department of Medicine, The University of Hong Kong, Hong Kong.
authors.forename: Man-Fung
authors.initials: MF
authors.lastname: Yuen
authors.affiliation: Division of Hepatology, University of Indonesia, Jakarta, Indonesia.
authors.forename: Laurentius A
authors.initials: LA
authors.lastname: Lesmana
authors.affiliation: Department of Gastroenterology, Dayanand Medical College, Ludhiana, India.
authors.forename: Ajit
authors.initials: A
authors.lastname: Sood
authors.affiliation: Division of Hepatobiliary and Pancreatic Surgery, and Liver Transplantation, Department of Surgery, The University of Hong Kong, Hong Kong.
authors.forename: Albert
authors.initials: A
authors.lastname: Chan
authors.affiliation: The Institute of Translational Hepatology, Beijing, China.
authors.forename: George K
authors.initials: GK
authors.lastname: Lau
authors.affiliation: Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China.
authors.forename: Ji Dong
authors.initials: JD
authors.lastname: Jia
authors.affiliation: Beijing Youan Hospital, Capital Medical University, Beijing, China.
authors.forename: Zhongping
authors.initials: Z
authors.lastname: Duan
authors.affiliation: Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan.
authors.forename: Chen
authors.initials: C
authors.lastname: Yu
authors.affiliation: Department of Gastroenterology and Nephrology, Graduate School of Medicine, Chiba University, Chiba, Japan.
authors.forename: Osamu
authors.initials: O
authors.lastname: Yokosuka
authors.affiliation: Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Priyanka
authors.initials: P
authors.lastname: Jain
authors.affiliation: Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Ajeet S
authors.initials: AS
authors.lastname: Bhadoria
authors.affiliation: Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Guresh
authors.initials: G
authors.lastname: Kumar
authors.affiliation: Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences, New Delhi, India.
authors.forename: Shiv K
authors.initials: SK
authors.lastname: Sarin
mesh_terms: D065290:Acute-On-Chronic Liver Failure / Q000150:complications* / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D000328:Adult; D005260:Female; D006801:Humans; D016031:Liver Transplantation; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology / Q000517:prevention & control; D011446:Prospective Studies; D018805:Sepsis / Q000209:etiology / Q000517:prevention & control; D015996:Survival Rate; D018746:Systemic Inflammatory Response Syndrome / Q000209:etiology* / Q000517:prevention & control; D013997:Time Factors
keywords: ACLF; SIRS; golden window