Predictors of Acute Liver Failure in Patients With Acute Hepatitis A: An Analysis of the 2016–2018 San Diego County Hepatitis A Outbreak. (5th November 2019)

• Record Type: Journal Article
• Authors: Jiang, Aiyang A; Greenwald, Holly S; Sheikh, Lamiya; Wooten, Darcy A; Malhotra, Atul; Schooley, Robert T; Sweeney, Daniel A
• Is Part Of: Open forum infectious diseases. Volume 6:Number 11(2019)
• Publication Date: 2019-11-05
• Subjects: acute liver failure -- hepatitis A -- MELD-Na score -- serum albumin; Communicable diseases -- Periodicals; Medical microbiology -- Periodicals; Infection -- Periodicals; 616.9
• DOI: 10.1093/ofid/ofz467
• Languages: English
• ISSNs: 2328-8957

Abstract

Abstract: Background: Between 2016 and 2018, San Diego County experienced a hepatitis A outbreak with a historically high mortality rate (3.4%) that highlighted the need for early recognition of those at risk of developing acute liver failure (ALF). Methods: A retrospective case series of adult hospitalized patients with acute hepatitis A. Results: One hundred six patients with hepatitis A were studied, of whom 11 (10.4%) developed ALF, of whom 7 (6.6%) died. A history of alcohol abuse, hyperbilirubinemia, hypoalbuminemia, hyponatremia, and anemia were associated with increased odds of developing ALF. Initial Maddrey's and Model of End-Stage Liver Disease Sodium (MELD-Na) scores were also associated with the development of ALF. Multivariable analysis showed that a higher initial MELD-Na score (odds ratio [OR], 1.205; 95% confidence interval [CI], 1.018–1.427) and a lower initial serum albumin concentration (OR, 9.35; 95% CI, 1.15–76.9) were associated with increased odds of developing ALF. Combining serum albumin and MELD-Na (SAM; C-statistic, 0.8878; 95% CI, 0.756–0.988) yielded a model that was not better than either serum albumin (C-statistic, 0.852; 95% CI, 0.675–0.976) or MELD-Na (C-statistic, 0.891; 95% CI, 0.784–0.968; P = .841). Finally, positive blood cultures were more common among patients with ALF compared with those without ALF (63.6% vs 4.3%; P < .00001). Conclusions: Hypoalbuminemia was associated with an increased risk of ALF in patients with acute hepatitis A. Positive blood cultures and septic shock as a cause of death were common among patients with ALF. Providers caring for patients with acute hepatitis A should monitor for early signs of sepsis and consider empiric antibiotics, especially in patients presenting with hypoalbuminemia. Abstract : The San Diego hepatitis A outbreak of 2017-18 was one of the largest person-to-person outbreaks in the US since 1996. Our analysis of 109 patients from this outbreak identified hypoalbuminemia as the single best predictor of acute liver failure.