Treatment updates for sepsis cases in liver cirrhosis

Liver cirrhosis with sepsis is associated with high mortality, with patients generally treated with approximate guidelines valid for non-cirrhotic patients. A recent review proposes a sepsis management guideline, although strong evidence is lacking.

A recent review proposes specific guidelines for this type of patient

Sepsis in patients with liver cirrhosis is associated with high mortality.  The optimal management of these patients has not been established, they are generally treated on the basis of guidelines valid for non-cirrhotic patients. Despite the absence of strong evidence, a recent review published in Hepatology proposes an approach to sepsis for this specific category of patients.

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Sepsis is defined as a life-threatening organ dysfunction caused by an inappropriate host response to the infection. This is one of the clinical syndromes that are of most interest worldwide, especially as incidence and mortality are steadily increasing. Epidemiological data show an incidence in the European Union of about 90 cases per 100,000 inhabitants per year, with an estimated 1.4 million cases of sepsis per year and a mortality rate ranging, depending on the areas concerned, between 20 and 40%.

In patients with liver cirrhosis, the onset of sepsis is associated with high mortality. Sepsis in the cirrhotic patient is in fact particularly insidious: while on the one hand, the immunosuppression related to the disease makes the cirrhotic patients at greater risk of infection, on the other hand, the hemodynamic and systemic signs suggestive of sepsis can be seen even in the absence of infection, thus delaying the diagnosis.

The specific characteristics of the disease, such as the reduced white blood cell count due to hypersplenism, tachycardia, hyperventilation and mental confusion due to liver encephalopathy make differential diagnosis difficult, thus delaying the administration of bundles of therapy (volume, antibiotic and vasopressors), whose early application is essential.

The anatomical and functional alterations typical of the disease (e.g. endo-abdominal hypertension for ascites) also make hemodynamic monitoring more complex, affecting parameters often used for this purpose such as PVC or collapse of the vena cava. 

Hyperlactacidemia may be present even in the absence of sepsis. A panel of experts recommends hemodynamic monitoring using a central venous catheter, arterial line, and possible pulmonary arterial catheter, especially in those patients with right ventricular failure or suspected pulmonary hypertension. Noradrenaline remains the vasoconstrictor of choice, but there seems to be an improvement in outcome when associated with vasopressin, which mobilizes the splanchnic region.

Finally, albumin plays an important role: recent studies on the use of this protein in sepsis are not specific for cirrhotic patients, in whom a chronic hypoalbuminemia is to be taken into account.

- Simonetto DA, Piccolo Serafim L, Gallo de Moraes A, Gajic O, Kamath PS. Management of Sepsis in Patients with Cirrhosis: current evidence and practical approach. Hepatology. 2018 Dec 5.
doi: 10.1002/hep.30412
- Nadim MK, Durand F, Kellum JA, et al. Management of the critically ill patient with cirrhosis: A multidisciplinary perspective. Journal of hepatology. 2016;64(3):717-7