P: 35 Hepatic Encephalopathy Is an Independent Risk Factor for the Occurrence of Infection in Cirrhotic Patients With Acute Decompensation

Abstract

BACKGROUND: Hepatic encephalopathy (HE) in cirrhotic patients increases mortality with worsening of HE grade 1. Infection is important in the pathogenesis and a common reason for progression to HE and death in these patients 2. However, HE role as a predisposing factor to infection in patients with acute decompensation (AD) is not known. It's recently shown that CNS injury leads to secondary immunodeficiency, and significantly increases susceptibility to infection (Pneumonia is the commonest serious complication with stroke 3), with development of the so known CNS injury-induced immunodepression (CIDS). But those studies focused only on organic brain injuries, like stroke, TBI and SCI4. Our study aims to determine whether HE is associated with the development of new infections in cirrhotic patients with AD. METHODS: Patients were identified at two institutions (AIIMS & UCL) as part of ongoing prospective studies of AD. Culture positive Infections and severity of HE (classified by West Haven Criteria) were measured on the day of admission, and new culture positive infections were assessed for up to 28 days after admission. Organ failures were defined as CLIF-organ failure score. Cox-proportional hazard analysis was used to assess predictors of infection. RESULTS: 759 cirrhotic patients with AD were included with a median age of 45 years, and varying degrees of HE; grade 0/1 (n = 452), grade 2–4 (n = 307). On day 0, Patients classified into 4 groups; no HE no infection (n = 359), overt HE no infection (n = 222), no HE with infection (n = 93), overt HE with infection (n = 85). OFs (Liver, Renal, Brain, Coagulation, Respiratory, and Circulatory) and ACLF grades were measured on Day 0, with ACLF grade 0, 1, 2, and 3 (n = 242, 99, 206, and 212 respectively). On univariate and multivariate analyses, Overt HE (with no baseline infection) was independently predictive of new infections (1.639 and 1.608; P = 0.006, and 0.016 respectively). Furthermore, age and circulatory failure were also independent risk factors for infection (P = 0.001, and 0.017 respectively). Overall, HE was higher in non-survivors (n = 191) compared to survivors (n = 116). CONCLUSIONS: The results of this study show for the first time that, in AD patients, overt HE not only associated with higher mortality but is also an independent risk factor for infection. We also showed that Age and Circulatory failure are independent risk factors for infections. That would make them, after further studies, an indication for prophylactic antibiotics.