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Evaluating the role of C-reactive protein in patients with cirrhosis needs mindful interpretation.

I read with interest the recently published article by Perdigoto et al. [1], where the authors have reported that ultrasensitive-C-reactive protein (us-CRP) has an excellent ability to differentiate patients having cirrhosis with infection from those without infection and have suggested us-CRP cut-off values to lie between 2.40 and 3.92mg/dl. This is a well-conducted study; however, interpretation of such results must be mindful of some facts: first, us-CRP was used as a predictor of infection; second, systemic inflammatory response syndrome (SIRS) was not considered as an inclusion criteria for infection; and finally, the analysis was based on one-time measurement of usCRP. Unlike conventional CRP, us-CRP is considered a biomarker for cardiovascular risk rather than overt inflammation [2]. It is generally used to measure lower concentrations of CRP for risk assessment of cardiovascular diseases. Such measurement in patients with infection may lead to misinterpretation of results because of the ‘hook effect’. Noninclusion of patients with SIRS and analysis based on time measurement of CRP may produce erroneous results because SIRS can be induced by occult bacterial infection in patients with cirrhosis, and CRP levels can remain elevated for several days despite the resolution of infection. Data are variable about optimal CRP cut-offs (9.2–80mg/l) to differentiate patients having cirrhosis with or without infection [3]. Here, authors have suggested a lower CRP cutoff for predicting infection. CRP is primarily synthesized in the liver in response to cytokines, mainly interleukin-6 (IL-6). A study has found that CRP correlates weakly with IL-6 levels in patients with cirrhosis having infection [4]. Because of a decreased synthetic ability of failing liver and defective response to IL-6, patients with advanced cirrhosis may present reduced CRP in response to infection. Therefore, even mild to moderate increase in CRP levels in such patients should not be disregarded.