Defining a ‘golden window' period and relevance of systemic inflammatory response syndrome (SIRS) in acute on chronic liver failure (ACLF) a tool for intervention and improved survival

Abstract

BACKGROUND AND AIMS: Systemic Inflammatory Response Syndrome (SIRS) is an early marker of sepsis and ongoing inflammation. Sepsis is the most common cause of mortality. The aim is to study the natural course of SIRS and sepsis in a hospitalized ACLF cohort without SIRS, sepsis at baseline and to define a window period for possible intervention. METHODS: Consecutive hospitalized patient of ACLF were prospectively evaluated for the development of SIRS/sepsis and associated complications till 90 days follow up, liver transplant or death. All patients received standard medical care, sepsis screening was done for initial 15 days, followed by ‘on suspicion’ screening. RESULTS: 201 patients with median age 46 yr (IQR = 38–45), male (91 %) and majority of ethanol (47 %) etiology. New onset SIRS, sepsis and septic shock at the end of first week were (77.6, 10 and 1 %) respectively. The time to development of SIRS, sepsis were 6.18 ± 1.7 and 7 days (IQR 4–7) respectively. Rate of development or resolution of SIRS 11–12 % per day. Development of SIRS associated with procalcitonin positivity (P = 0.05). Increasing no of organ failure (0, 3, 4) associated with higher incidence of SIRS (24, 87.5 and 100 % respectively, P\0.05). SIRS at D7 leads to a median survival (12 vs. 29 weeks), first week mortality (23 % vs. none, P\0.005) and 90 days mortality of (51.9 % vs. 37.8 %, P = 0.12). CONCLUSION: SIRS and its dynamicity is an important predictor of early sepsis, organ failure and survival in ACLF. Prompt use of prophylactic antibiotics with onset SIRS and rigorous septic screen during in the Golden window could improve outcome.