Acute-on-Chronic Liver Failure
In patients with cirrhosis, spontaneous bacterial peritonitis and other bacterial infections are associated with a high risk of acute kidney failure and short-term mortality. There are data indicating that infected patients with cirrhosis develop kidney failure in the context of an intense inflammatory response. Patients with cirrhosis and spontaneous bacterial peritonitis (or other type of bacterial infections) who have moderate increases in leukocytes, proinflammatory cytokines, tumor necrosis factor-α, and interleukin-6 in both plasma and ascitic fluid usually do not develop kidney failure and have a low risk of in-hospital death. Therefore, it appears that kidney failure associated with bacterial infections is related more to the intensity of the immune response than to the type of infection or the responsible organism.
Not surprisingly, in the CANONIC study the white cell count and plasma C-reactive protein levels were higher in patients with ACLF than in those without (Table 2). Furthermore, the severity of ACLF grade correlated directly with the degree of inflammation, thus indicating that ACLF is associated with marked systemic inflammation. It could be argued that the higher prevalence of spontaneous bacterial peritonitis and pneumonia in the ACLF group could account for this feature (Table 2). However, the higher white cell count and C-reactive protein levels also were observed in the subgroup of patients with ACLF unrelated to bacterial infection. Of note, in patients with ACLF, a higher white cell count is an independent predictor of 28-day transplant-free mortality.
Acute on Chronic Liver Failure Is Associated With Systemic Inflammation
In patients with cirrhosis, spontaneous bacterial peritonitis and other bacterial infections are associated with a high risk of acute kidney failure and short-term mortality. There are data indicating that infected patients with cirrhosis develop kidney failure in the context of an intense inflammatory response. Patients with cirrhosis and spontaneous bacterial peritonitis (or other type of bacterial infections) who have moderate increases in leukocytes, proinflammatory cytokines, tumor necrosis factor-α, and interleukin-6 in both plasma and ascitic fluid usually do not develop kidney failure and have a low risk of in-hospital death. Therefore, it appears that kidney failure associated with bacterial infections is related more to the intensity of the immune response than to the type of infection or the responsible organism.
Not surprisingly, in the CANONIC study the white cell count and plasma C-reactive protein levels were higher in patients with ACLF than in those without (Table 2). Furthermore, the severity of ACLF grade correlated directly with the degree of inflammation, thus indicating that ACLF is associated with marked systemic inflammation. It could be argued that the higher prevalence of spontaneous bacterial peritonitis and pneumonia in the ACLF group could account for this feature (Table 2). However, the higher white cell count and C-reactive protein levels also were observed in the subgroup of patients with ACLF unrelated to bacterial infection. Of note, in patients with ACLF, a higher white cell count is an independent predictor of 28-day transplant-free mortality.
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