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J Clin Exp Hepatol. 2019 Mar-Apr;9(2):162-170. doi: 10.1016/j.jceh.2018.04.006. Epub 2018 May 17.
A/H1N1/09 Influenza is Associated With High Mortality in Liver Cirrhosis.
Premkumar M1, Devurgowda D1, Dudha S1, Maiwall R1, Bihari C2, Grover S2, Gupta E3, Kumar S4, Sarin SK1.
Author information
Abstract
Background/Aims:
A/H1N1/09 influenza is associated with a high risk of complications in patients with chronic diseases. In view of patients with cirrhosis being recognized as another high-risk group for influenza morbidity and mortality, we report a cluster of suspected A/H1N1/09 infection in 110 patients admitted to a hepatology intensive care unit.
Methods:
The pattern of spread, clinical outcome, and respiratory parameters of A/H1N1/09 of 22 positive cirrhotic patients were compared with those from a control group of 88 patients with chronic liver disease (CLD) with influenza-like pneumonia who tested negative for A/H1N1/09.
Results:
A/H1N1/09 infection was confirmed in 22 (20%) patients. Eighteen of 22 (81.8%) CLD patients with A/H1N1/09 died of pneumonia and acute respiratory distress syndrome despite timely antiviral treatment. In contrast, only 35 (40%)of the control group of cirrhotic patients without A/H1N1/09 died. On univariate analysis, age > 45 years [OR 1.3; 95% CI 1.1-5.7, (P = 0.054)], encephalopathy > grade 2 [OR 5.4; 95% CI 2.8-12.3, (P = 0.042)], serum bilirubin >8 mg/dl [OR 2.1; 95% CI 1.8-12.3, (P = 0.052)], serum creatinine >1.8 mg/dl [OR 2.8; 95% CI 1.9-9.2, (P = 0.042)], PaO2/FiO2 ratio <200 [OR 4.5; 95% CI 3.1-18.5, (P = 0.026)] and INR > 2.5 [OR 2.2; 95% CI 1.8-6.7, (P = 0.032)] were risk factors for mortality at presentation. However, on multivariate analysis only PaO2/FiO2 ratio <200 and serum creatinine >1.8 mg/dl remained predictors of mortality. Secondary infections, whether fungal or bacterial, were noted to be independent risk factors for disease severity in patients with cirrhosis.
Conclusion:
Early detection and referral, and early antiviral treatment with a strict control of nosocomial spread is essential in patients with cirrhosis during epidemic influenza.
KEYWORDS:
AKI, Acute Kidney Injury; APACHE II, Acute Physiologic Assessment and Chronic Health Evaluation II; ARDS, Acute Respiratory Distress Syndrome; CLD, Chronic Liver Disease; CTP, Child Turcotte Pugh Score; CXR, Chest Radiograph; H1N1 influenza; ICU, Intensive Care Unit; ILI, Influenza Like Illness; INR, International Normalized Ratio; MELD, Model for End-Stage Liver Disease; NASH, Non Alcoholic Steatohepatitis; PCR, Polymerase Chain Reaction; SOFA, Sequential Organ Failure Score; critical care in liver disease; pneumonia; ventilatory support
PMID: 31024197 PMCID: PMC6477137 [Available on 2020-03-01] DOI: 10.1016/j.jceh.2018.04.006
A/H1N1/09 Influenza is Associated With High Mortality in Liver Cirrhosis.
Premkumar M1, Devurgowda D1, Dudha S1, Maiwall R1, Bihari C2, Grover S2, Gupta E3, Kumar S4, Sarin SK1.
Author information
Abstract
Background/Aims:
A/H1N1/09 influenza is associated with a high risk of complications in patients with chronic diseases. In view of patients with cirrhosis being recognized as another high-risk group for influenza morbidity and mortality, we report a cluster of suspected A/H1N1/09 infection in 110 patients admitted to a hepatology intensive care unit.
Methods:
The pattern of spread, clinical outcome, and respiratory parameters of A/H1N1/09 of 22 positive cirrhotic patients were compared with those from a control group of 88 patients with chronic liver disease (CLD) with influenza-like pneumonia who tested negative for A/H1N1/09.
Results:
A/H1N1/09 infection was confirmed in 22 (20%) patients. Eighteen of 22 (81.8%) CLD patients with A/H1N1/09 died of pneumonia and acute respiratory distress syndrome despite timely antiviral treatment. In contrast, only 35 (40%)of the control group of cirrhotic patients without A/H1N1/09 died. On univariate analysis, age > 45 years [OR 1.3; 95% CI 1.1-5.7, (P = 0.054)], encephalopathy > grade 2 [OR 5.4; 95% CI 2.8-12.3, (P = 0.042)], serum bilirubin >8 mg/dl [OR 2.1; 95% CI 1.8-12.3, (P = 0.052)], serum creatinine >1.8 mg/dl [OR 2.8; 95% CI 1.9-9.2, (P = 0.042)], PaO2/FiO2 ratio <200 [OR 4.5; 95% CI 3.1-18.5, (P = 0.026)] and INR > 2.5 [OR 2.2; 95% CI 1.8-6.7, (P = 0.032)] were risk factors for mortality at presentation. However, on multivariate analysis only PaO2/FiO2 ratio <200 and serum creatinine >1.8 mg/dl remained predictors of mortality. Secondary infections, whether fungal or bacterial, were noted to be independent risk factors for disease severity in patients with cirrhosis.
Conclusion:
Early detection and referral, and early antiviral treatment with a strict control of nosocomial spread is essential in patients with cirrhosis during epidemic influenza.
KEYWORDS:
AKI, Acute Kidney Injury; APACHE II, Acute Physiologic Assessment and Chronic Health Evaluation II; ARDS, Acute Respiratory Distress Syndrome; CLD, Chronic Liver Disease; CTP, Child Turcotte Pugh Score; CXR, Chest Radiograph; H1N1 influenza; ICU, Intensive Care Unit; ILI, Influenza Like Illness; INR, International Normalized Ratio; MELD, Model for End-Stage Liver Disease; NASH, Non Alcoholic Steatohepatitis; PCR, Polymerase Chain Reaction; SOFA, Sequential Organ Failure Score; critical care in liver disease; pneumonia; ventilatory support
PMID: 31024197 PMCID: PMC6477137 [Available on 2020-03-01] DOI: 10.1016/j.jceh.2018.04.006