Michelena Javier, Altamirano José, Abraldes Juan G, Affò Silvia, Morales-Ibanez Oriol, Sancho-Bru Pau, Dominguez Marlene, García-Pagán Juan Carlos, Fernández Javier, Arroyo Vicente, Ginès Pere, Louvet Alexandre, Mathurin Philippe, Mehal Wajahat Z, Caballería Juan, Bataller Ramón
Liver Unit, Hospital Clínic, Barcelona, Spain.
Institut d'Investigacions Biomèdiques August-Pi-Sunyer, University of Barcelona, Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Barcelona, Spain.
Hepatology. 2015 Sep;62(3):762-72. doi: 10.1002/hep.27779. Epub 2015 Apr 13.
Alcoholic hepatitis (AH) frequently progresses to multiple organ failure (MOF) and death. However, the driving factors are largely unknown. At admission, patients with AH often show criteria of systemic inflammatory response syndrome (SIRS) even in the absence of an infection. We hypothesize that the presence of SIRS may predispose to MOF and death. To test this hypothesis, we studied a cohort including 162 patients with biopsy-proven AH. The presence of SIRS and infections was assessed in all patients, and multivariate analyses identified variables independently associated with MOF and 90-day mortality. At admission, 32 (19.8%) patients were diagnosed with a bacterial infection, while 75 (46.3%) fulfilled SIRS criteria; 58 patients (35.8%) developed MOF during hospitalization. Short-term mortality was significantly higher among patients who developed MOF (62.1% versus 3.8%, P < 0.001). The presence of SIRS was a major predictor of MOF (odds ratio = 2.69, P = 0.025) and strongly correlated with mortality. Importantly, the course of patients with SIRS with and without infection was similar in terms of MOF development and short-term mortality. Finally, we sought to identify serum markers that differentiate SIRS with and without infection. We studied serum levels of high-sensitivity C-reactive protein, procalcitonin, and lipopolysaccharide at admission. All of them predicted mortality. Procalcitonin, but not high-sensitivity C-reactive protein, serum levels identified those patients with SIRS and infection. Lipopolysaccharide serum levels predicted MOF and the response to prednisolone.
In the presence or absence of infections, SIRS is a major determinant of MOF and mortality in AH, and the mechanisms involved in the development of SIRS should be investigated; procalcitonin serum levels can help to identify patients with infection, and lipopolysaccharide levels may help to predict mortality and the response to steroids.
酒精性肝炎（AH）常进展为多器官功能衰竭（MOF）并导致死亡。然而，其驱动因素在很大程度上尚不清楚。入院时，AH患者即使没有感染也常表现出全身炎症反应综合征（SIRS）的标准。我们假设SIRS的存在可能易导致MOF和死亡。为验证这一假设，我们研究了一个队列，其中包括162例经活检证实为AH的患者。评估了所有患者SIRS和感染的存在情况，并通过多变量分析确定了与MOF和90天死亡率独立相关的变量。入院时，32例（19.8%）患者被诊断为细菌感染，而75例（46.3%）符合SIRS标准；58例患者（35.8%）在住院期间发生了MOF。发生MOF的患者短期死亡率显著更高（62.1%对3.8%，P < 0.001）。SIRS的存在是MOF的主要预测因素（优势比=2.69，P = 0.025），且与死亡率密切相关。重要的是，有无感染的SIRS患者在MOF发生和短期死亡率方面病程相似。最后，我们试图确定区分有无感染的SIRS的血清标志物。我们研究了入院时高敏C反应蛋白、降钙素原和脂多糖的血清水平。所有这些都可预测死亡率。降钙素原而非高敏C反应蛋白的血清水平可识别有SIRS和感染的患者。脂多糖血清水平可预测MOF及对泼尼松龙的反应。
无论有无感染，SIRS都是AH中MOF和死亡率的主要决定因素，应研究SIRS发生发展的机制；降钙素原血清水平有助于识别感染患者，脂多糖水平可能有助于预测死亡率及对类固醇的反应。
