The aim of this prospective, longitudinal selleck products observational study was to determine the role of these key pathophysiological variables in ACLF patients with or without associated HE. Methods: 101 patients (M/F: 69/32; mean age: 54; Alcohol: 78%) with ACLF admitted to ICU were studied. The severity of ACLF was classified using the CLIF-SOFA score and the severity of HE using the West-Haven
criteria. All patients were managed according to a pre-defined protocol and organ support was provided as required. Arterial ammonia, jugular venous oxygen saturation (JVO2), white cell count (WCC) and CRP were measured at time of enrolment, at days, 1, 3 and 7 or, until death or discharge. Results: 51 patients died (50.5%). Mortality was higher in ACLF patients with HE (ACLF-HE) irrespective of the severity of ACLF (ACLF-HE: 35/53 (66%); ACLF-no HE: 16/48 (33%), p = 0.001). Mortality was greater in patients with greater severity of HE (Grade 0/1: 16/48 (33%) Grade DZNeP mouse 2: 19/32 (59%) Grade 3-4 16/21 (76%), p = 0.002). INR, creatinine, WCC, low platelets at baseline, and ACLF severity were independent predictors of death in the whole cohort and in the ACLF-HE cohort. Baseline ammonia levels were higher in HE patients (90 vs 73 umol/L; p = 0.004) but did not predict mortality. A decrease in ammonia level was associated with
better survival (p <0.001). Abnormal baseline JVO2 (deviation by more than 5% from an optimal 75%) was associated with both presence and severity of HE (ACLF-no HE:
22%; ACLF-HE Grade 2: 47%; ACLF-HE Grade 3-4: 62%, p = 0.005). Worsening JVO2 (low or high) was independently associated with mortality (improved JVO2: 21% mortality; worsened 79%, p <0.001). WCC did not differ between non-HE and HE groups at baseline (p = 0.95) but WCC was higher in the group that died (p = 0.007). A further increase was independently predictive of death (p <0.001). There was a strong interaction between ammonia and JV02 in regards to predicting the severity of HE and mortality. Conclusions: The data in this study describes potential mechanisms of HE in ACLF indicating that ammonia and abnormal cerebral oxygenation are pathophysiologically important. These findings suggest that ammonia and JVO2 Sclareol as well as WCC are important biomarkers for prognosis and also important therapeutic targets. Whether the altered JVO2 is independent of ammonia in the pathogenesis of HE in ACLF requires future study. Disclosures: Rajiv Jalan – Consulting: Ocera Therapeutics, Conatus; Grant/Research Support: Grifols, Gambro The following people have nothing to disclose: Rohit Sawhney, Peter Holland-Fischer, Rajeshwar Mookerjee, Matteo Rosselli, Banwari Agarwal Background: Infection is a major cause of mortality in acute on chronic liver failure (ACLF). Immuneparesis, monocyte dysfunction, is postulated to account for the increased susceptibility to infection.