A/H1N1/09 Influenza is Associated With High Mortality in Liver Cirrhosis

Madhumita Premkumar; Devaraja Devurgowda; Shivani Dudha; Rakhi Maiwall; Chhagan Bihari; Shrruti Grover; Ekta Gupta; Sachin Kumar; Shiv K Sarin

doi:10.1016/j.jceh.2018.04.006

A/H1N1/09 Influenza is Associated With High Mortality in Liver Cirrhosis

J Clin Exp Hepatol. 2019 Mar-Apr;9(2):162-170. doi: 10.1016/j.jceh.2018.04.006. Epub 2018 May 17.

Authors

Madhumita Premkumar¹, Devaraja Devurgowda¹, Shivani Dudha¹, Rakhi Maiwall¹, Chhagan Bihari², Shrruti Grover², Ekta Gupta³, Sachin Kumar⁴, Shiv K Sarin¹

Affiliations

¹ Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, India.
² Department of Pathology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, India.
³ Department of Virology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, India.
⁴ Department of Pulmonology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, India.

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.