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
Journal of Clinical and Experimental Hepatology 2019, 9 (2): 162-170

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.

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