Introduction To evaluate the incidence of liver dysfunction in septic patients and to determine the best available biomarker widely available as a diagnostic and prognostic marker of mortality.
Methods Adult inpatients (aged over 18) with positive blood cultures were identified from the microbiology database between Jan 2012 and June 2012. Total protein, albumin, bilirubin, ALP and ALT were recorded pre, peri and post sepsis. Peak derangement of liver function test (LFT) was evaluated. Hb, WCC, Plt and CRP were recorded on the date of positive blood culture. Patients fell into 3 groups; normal liver function, alcoholic liver disease and non-alcoholic liver disease. Kaplan Meier survivorship scores and ROC curves were calculated in SPSSR.
Results 93 of 140 patients with positive blood cultures had abnormal LFTs during admission. 71 medical case records were available for review. 41 patients had normal LFTs prior to admission, 30 had pre-existing liver disease with abnormal LFTs (8 ALD; 22 with malignancy). The median age of the cohort was 66.7 yrs (23–93) with an equal sex distribution (35 M:37 F). 47/71 patients had deranged LFTs prior to documented bacteraemia, 19/71 on the day of bacteraemia and 5/71 after.
Bilirubin was the most sensitive parameter of the LFT in predicting mortality prior to organism culture,calculated using ROC curves with an area of 0.59. Following positive blood culture, bilirubin, ALT and CRP rises are indicators of mortality with areas of 0.64, 0.55 and 0.55 respectively. The ROC curves were not statistically significant for Hb, WCC and platelets prior to,or after the onset of bacteraemia.
4 patients died within 24 h, 4 between 24–72 h and 7 between 72 h and 30 days. The overall mortality was 30% lower than a comparative study at 44.7% (median age 66.7).1 There was no statistically significant difference in mortality from sepsis with pre-existing liver disease (alcoholic or malignant) compared to no existing liver disease.
Sepsis-induced liver dysfunction was present on admission in 66% of septic patients with previously normal LFT’s, 27% prior to positive blood cultures and 5% after positive blood cultures. This is comparative to an incidence at admission of 58.3% in a recent study.1 The relative risk of mortality in the presence of sepsis induced liver injury was 1.82.
Conclusion Sepsis-induced liver dysfunction is common and clinically important to identify and has prognostic implications. Abnormal liver function can precede organism culture. There is currently no widely available gold standard test reflecting liver failure. Bilirubin is a diagnostic and prognostic marker of mortality before and after the onset of sepsis. ALT and CRP are useful after the onset of sepsis.
Kobashi et al. Sepsis associated liver injury:Incidence,classification and the clinical significance. Hepatology Research 2013;43:255–266
Disclosure of Interest None Declared.
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