Department of Internal Medicine I, University Hospital Bonn, Bonn, Germany.
Center for Cirrhosis and Portal Hypertension Bonn (CCB), University Hospital Bonn, Bonn, Germany.
Liver Transpl. 2023 Sep 1;29(9):928-939. doi: 10.1097/LVT.0000000000000135. Epub 2023 Mar 24.
Acute-on-chronic liver failure (ACLF) is associated with organ failure and high short-term mortality. Bacterial infections and surgery have been reported as major precipitants for ACLF. However, detailed characterization of postoperative infections after elective surgery in patients with liver cirrhosis and their impact on the development of ACLF have not been investigated yet. A total of 235 patients with cirrhosis without ACLF and proven bacterial infections undergoing elective surgery were included. The primary end point was the development of ACLF within 28 days after surgery, and secondary end points were infection development within 28 days and 3-month ACLF-related mortality. Cox regression analysis was used for identification of risk factors associated with ACLF development, infection development, and mortality. A total of 86 patients (37%) developed ACLF within 28 days after surgery. Patients with new postoperative infections had significantly higher rates of associated ACLF episodes within 28 days (51% vs. 24%, p < 0.001) and higher 3-month mortality ( p < 0.05) than patients without postoperative infections. New infections after surgery [HR: 2.43 (1.59-3.71), p < 0.001] and organ/space surgical site infections [HR: 2.46 (1.26-4.80), p = 0.01] in particular were independent risk factors associated with ACLF development 28 days after surgery. Extensive procedures were associated with the development of new postoperative infection episodes within 28 days. Infections treated with initial appropriate empirical antibiotic strategies showed significantly improved survival. This study characterizes and identifies bacterial infections in general and organ/space surgical site infection in particular as precipitating events for the development of ACLF after elective surgery in patients with cirrhosis. Postoperative ACLF combined with infections leads to higher postoperative short-term mortality than each condition separately, especially in extensive procedures. Interdisciplinary care, early identification of postoperative ACLF and infections, and adequate, broad, and early treatment strategies are needed to improve postoperative outcome.
慢加急性肝衰竭（ACLF）与器官衰竭和高短期死亡率相关。细菌感染和手术已被报道为 ACLF 的主要诱因。然而，尚未对肝硬化患者择期手术后的术后感染进行详细描述及其对 ACLF 发展的影响。共纳入 235 例无 ACLF 和已证实细菌感染的肝硬化患者行择期手术。主要终点为术后 28 天内发生 ACLF，次要终点为术后 28 天内和 3 个月 ACLF 相关死亡率。采用 Cox 回归分析确定与 ACLF 发展、感染发展和死亡率相关的危险因素。共有 86 例（37%）患者在术后 28 天内发生 ACLF。新发术后感染患者在术后 28 天内发生相关 ACLF 发作的比例明显更高（51% vs. 24%，p < 0.001），3 个月死亡率更高（p < 0.05）。术后新发感染（HR：2.43 [1.59-3.71]，p < 0.001）和器官/腔隙手术部位感染（HR：2.46 [1.26-4.80]，p = 0.01）尤其与术后 28 天 ACLF 发展相关。广泛的手术与术后 28 天内新发感染发作相关。初始适当经验性抗生素治疗的感染患者的生存率显著提高。本研究对肝硬化患者择期手术后 ACLF 的发生与一般细菌感染和器官/腔隙手术部位感染之间的关系进行了描述和鉴定。术后 ACLF 合并感染比单独发生每种情况导致更高的术后短期死亡率，尤其是在广泛的手术中。需要多学科的护理、早期识别术后 ACLF 和感染，以及充分、广泛和早期的治疗策略，以改善术后结果。
