A Drolz

Von Willebrand factor antigen for detection of hepatopulmonary syndrome in patients with cirrhosis.

BACKGROUND & AIMSnHepatopulmonary syndrome (HPS) occurs in 20-30% of patients with liver cirrhosis and is associated with a >2 fold increased mortality. Endothelial dysfunction seems to play a central role in its pathogenesis. von Willebrand factor antigen (vWF-Ag), an established marker of endothelial dysfunction, is significantly elevated in patients with liver cirrhosis, portal hypertension, and in experimental HPS. Aim of the present study was to evaluate the impact of vWF-Ag as a screening marker for presence of HPS in patients with stable cirrhosis.nnnMETHODSn145 patients with stable liver cirrhosis were screened for presence of HPS in this prospective cohort type cross sectional diagnostic study. vWF-Ag and SaO2 levels were assessed at time of screening for HPS. Criteria of HPS were fulfilled in 31 (21%) patients.nnnRESULTSnvWF-Ag levels were significantly higher in patients with HPS compared to patients without HPS (p<0.001). Furthermore, vWF-Ag correlated significantly with gas exchange in HPS positive patients (p<0.05). vWF-Ag is an independent predictor of HPS after correction for sex, age, model for endstage-liver disease (MELD), and hepatic venous pressure gradient (HVPG) (OR per 1% increase of vWF-Ag: 1.02, 95% CI: 1.00-1.04, p<0.05). The best cut-off was 328% at a sensitivity of 100% and specificity of 53.5%; positive predictive value: 36.9%; negative predictive value: 100%.nnnCONCLUSIONSnHPS is associated with elevated vWF-Ag levels. vWF-Ag may be a useful screening tool for early detection of HPS. Further studies investigating vWF-Ag in HPS will be needed to confirm our findings.

Outcome and features of acute kidney injury complicating hypoxic hepatitis at the medical intensive care unit

BackgroundHypoxic hepatitis (HH) is a frequent and potentially life-threatening event typically occurring in critically ill patients as a consequence of hemodynamic impairment. While acute kidney injury (AKI) has been well described in patients with acute liver failure, incidence and outcome of AKI accompanying HH are unclear. The aim of this study was to assess incidence, clinical implications and outcome of AKI and renal replacement therapy (RRT) in critically ill patients with HH.MethodsA total of 1948 consecutive critically ill admissions were studied at the Medical University of Vienna. Laboratory and clinical parameters as well as the presence of HH and AKI were assessed on a daily basis. Outcome, renal recovery and length of stay were assessed and documented, and patients were followed for 1xa0year.ResultsA total of 295 admissions (15xa0%) developed HH. Main precipitators were cardiogenic (44xa0%) and septic shock (36xa0%). Occurrence of HH was significantly associated with AKI [OR 4.50 (95xa0% CI 3.30–6.12)] and necessity of renal replacement therapy [RRT; OR 3.36 (95xa0% CI 2.58–4.37)], pxa0<xa00.001 for both. Two hundred forty admissions with HH (81xa0%) developed AKI, 159 of whom (66xa0%) had AKI stage 3. Both HH and AKI were significantly linked to mortality. AKI stage 3, international normalized ratio (INR, during HH) and the presence of septic shock were identified as independent predictors of 28-day mortality in admissions with HH, whereas RRT was identified as an independent protective factor. There was a synergistic effect of HH and AKI on length of stay at the ICU. Of all HH survivors treated with RRT, 71xa0% showed renal recovery during follow-up.ConclusionHH is frequently complicated by occurrence of AKI. Severity of HH, AKI stage and the presence of septic shock seem to contribute to poor outcome in these patients. Initiation of RRT in HH with AKI may enable renal recovery and should not be withheld in medical ICU patients.

Circulating bile acids predict outcome in critically ill patients

BackgroundJaundice and cholestatic hepatic dysfunction are frequent findings in critically ill patients associated with increased mortality. Cholestasis in critically ill patients is closely associated with stimulation of pro-inflammatory cytokines resulting in impaired bile secretion and subsequent accumulation of bile acids.Aim of this study was to evaluate the clinical role of circulating bile acids in critically ill patients.MethodsTotal and individual serum bile acids were assessed via high-performance liquid chromatography in 320 critically ill patients and 19 controls.ResultsTotal serum bile acids were threefold higher in septic than cardiogenic shock patients and sixfold higher than in post-surgical patients or controls (pxa0<xa00.001). Elevated bile acid levels correlated with severity of illness, renal dysfunction and inflammation (pxa0<xa00.05). Total bile acids predicted 28-day mortality independently of sex, age, serum bilirubin and severity of illness (HR 1.041, 95% CI 1.013–1.071, pxa0<xa00.005). Best prediction of mortality of total bile acids was seen in patients suffering from septic shock.ConclusionsIndividual and total BAs are elevated by various degrees in different shock conditions. BAs represent an early predictor of short-term survival in a mixed cohort of ICU patients and may serve as marker for early risk stratification in critically ill patients. Future studies should elucidate whether modulation of BA metabolism and signalling influences the clinical course and outcome in critically ill patients.

Prognostic impact of ICG-PDR in patients with hypoxic hepatitis

AbstractBackgroundHepatic impairment is found in up to 20xa0% in criticallyn ill patients. Hypoxic/ischemic hepatitis (HH) is a diffuse hepatic damage associated with high morbidity and mortality. Indocyanine green plasma disappearance rate (ICG-PDR) is an effective tool assessing liver function in acute and chronic hepatic diseases. Aim of this study was to evaluate the prognostic impact of ICG-PDR in comparison to established parameters for risk stratification.MethodsPatients with HH were included in this prospective observational study and compared to cirrhosis, acute liver failure (ALF) and patients without underlying liver disease. ICG-PDR, measured non-invasively by finger pulse densitometry, was assessed on admission and in patients with HH serially and results were compared between groups. Diagnostic test accuracy of ICG-PDR predicting 28-day mortality was analyzed by receiver operating characteristics (ROC).ResultsICG-PDR on admission was significantly lower in patients with liver diseases than in patients without hepatic impairment (median 5.7xa0%/min, IQR 3.8–7.9 vs. 20.7 %/min, IQR 14.1–25.4xa0%/min; pxa0<xa00.001). ICG-PDR predicted 28-day mortality independently of SOFA score and serum lactate in patients with underlying liver disease (HR 1.27, 95xa0% CI 1.10–1.45, pxa0<xa00.001). In patients with HH, ICG-PDR was identified as best predictor of 28-day mortality which performed significantly better than SOFA, lactate, INR and AST over course of time (pxa0<xa00.05). Best cut-off for identification of 28-day survivors was ICG-PDR ≥9.0xa0%/min 48xa0h after admission.ConclusionsICG-PDR is an independent predictor of mortality in patients with liver disease. Diagnostic test accuracy of ICG-PDR was superior to standard liver function parameters and established scoring systems in patients with HH.

Lactate improves prediction of short‐term mortality in critically ill cirrhosis patients: a multinational study

Lactate levels and lactate clearance are known predictors of outcome in critically ill patients in the intensive care unit (ICU). The prognostic value of lactate is not well established in liver cirrhosis and acute‐on‐chronic liver failure (ACLF). The aim of this study was to assess the prognostic value of lactate levels and clearance in critically ill patients with cirrhosis. Patients with cirrhosis admitted to the ICU were studied at the University Medical Center Hamburg‐Eppendorf (n = 566, derivation cohort) and the Medical University of Vienna and the University Hospitals Leuven (n = 250, validation cohort). Arterial lactate was measured on admission and during the first 24 hours. Patients were followed for 1 year and outcome was assessed. Admission lactate was directly related to the number of organs failing and to 28‐day mortality (area under receiver operating characteristic [AUROC] 0.72; P < 0.001). This also applied to lactate follow‐up measurements after 6, 12, and 24 hours (P < 0.001 for all, AUROC > 0.70 for all). Lactate clearance had significant predictive ability for 28‐day mortality in patients with elevated serum lactate ≥5 mmol/L. Admission lactate and 12‐hour lactate clearance (in patients with admission lactate ≥5 mmol/L), respectively, were identified as significant predictors of 1‐year mortality, independent of Chronic Liver Failure Consortium acute‐on‐chronic liver failure score (CLIF‐C ACLFs). A lactate‐adjusted CLIF‐C ACLFs was developed (CLIF‐C ACLFsLact), which performed significantly better than the original CLIF‐C ACLFs in prediction of 28‐day mortality in the derivation and validation cohort. Conclusion: Lactate levels appropriately reflect severity of disease and organ failure and were independently associated with short‐term mortality in critically ill patients with liver cirrhosis. Lactate is a simple but accurate prognostic marker, and its incorporation improved performance of CLIF‐C ACLFs significantly.

Outcome of in- and out-of-hospital cardiac arrest survivors with liver cirrhosis

BackgroundOrgan failure increases mortality in patients with liver cirrhosis. Data about resuscitated cardiac arrest patients with liver cirrhosis are missing. This study aims to assess aetiology, survival and functional outcome in patients after successful cardiopulmonary resuscitation (CPR) with and without liver cirrhosis.MethodsAnalysis of prospectively collected cardiac arrest registry data of consecutively hospital-admitted patients following successful CPR was performed. Patient’s characteristics, admission diagnosis, severity of disease, course of disease, short- and long-term mortality as well as functional outcome were assessed and compared between patients with and without cirrhosis.ResultsOut of 1068 patients with successful CPR, 47 (4%) had liver cirrhosis. Acute-on-chronic liver failure (ACLF) was present in 33 (70%) of these patients on admission, and four patients developed ACLF during follow-up. Mortality at 1xa0year was more than threefold increased in patients with liver cirrhosis (OR 3.25; 95% CI 1.33–7.96). Liver cirrhosis was associated with impaired neurological outcome (OR for a favourable cerebral performance category: 0.13; 95% CI 0.04–0.36). None of the patients with Child–Turcotte–Pugh (CTP) C cirrhosis survived 28xa0days with good neurological outcome. Overall nine (19%) patients with cirrhosis survived 28xa0days with good neurological outcome. All patients with ACLF grade 3 died within 28xa0days.ConclusionCardiac arrest survivors with cirrhosis have worse outcome than those without. Although one quarter of patients with liver cirrhosis survived longer than 28xa0days after successful CPR, patients with CTP C as well as advanced ACLF did not survive 28xa0days with good neurological outcome.

Serum bile acids in patients with hepatopulmonary syndrome

Backgroundu2002Hepatopulmonary syndrome (HPS) occurs in 20u200a-u200a30u200a% of patients with cirrhosis and is associated with increased mortality. Cholestasis and accumulation of bile acids (BAs) play a major role in chronic liver disease. Aimu2002We aimed to evaluate the clinical role of serum BAs in patients with HPS. Methodsu2002Seventy-four patients with cirrhosis were included in this prospective study. Marker for cholestasis as total and individual serum BAs, bilirubin, alkaline phosphatase (AP), and gamma-glutamyl transpeptidase (GGT) were analyzed in patients screened for HPS.u200aCriteria of HPS were fulfilled in 26 patients (35u200a%). Resultsu2002In contrast to AP and GGT, bilirubin and serum BAs were significantly elevated in patients with HPS (median total BAs in HPS 83.5 μmol/L, IQR 43.1u200a-u200a148.9 vs. no HPS 26.9 μmol/L, 11u200a-u200a75.6; pu200a<u200a0.001). Total BAs correlated with gas exchange by means of PaO2u200a/u200aAaPO2 (r: -0.28, pu200a<u200a0.05; r: 0.24, pu200a<u200a0.05) and portal pressure (r: 0.33, pu200a<u200a0.05). BAs were associated with HPS independently severity of underlying liver disease (OR: 1.012, 95u200a% CI:xa01.001u200a-u200a1.023, pu200a<u200a0.05). Conclusionu2002BA retention is associated with HPS and gas exchange abnormalities. Future studies should assess whether modulation of BAs signaling may impact the course of HPS.

Epidemiology and outcome of cardiac arrest in patients with liver cirrhosis

Sudden cardiac arrest (CA) is one of the leading causes of death in adults in many parts of the world [1]. Every year estimated 350.000 to 700.000 people in Europe are suffering CA and receive cardiopulmonary resuscitation (CPR) [2]. To date, there is no data available on CA and CPR in patients with liver cirrhosis.

Gerinnungsparameter und Mortalität bei kritisch kranken Patienten mit Leberzirrhose – eine präliminäre Analyse

Einleitung: Veranderungen der Hamostase finden sich haufig bei Patienten mit Leberzirrhose. Der „disseminated intravascular coagulation score“ (DIC score) errechnet sich aus Routine-Gerinnungsparametern (Thrombozytenzahl, D-Dimere, Fibrinogen und Prothrombinzeit/-index) und ist ein bekannter Uberlebenspradiktor bei kritisch kranken Patienten. Aufgrund der Haufigkeit von „pathologischen“ Gerinnungsparametern bei Patienten mit Leberzirrhose ist bislang jedoch unklar, ob der DIC score eine prognostische Aussagekraft bei diesen Patienten besitzt. Ziele: Ziel dieser Studie ist die Bestimmung und die Beurteilung der Anwendbarkeit des DIC Score bei kritisch kranken Patienten mit Leberzirrhose. Methodik: Zirrhose-Patienten, die an der Intensivstation zur Aufnahme gelangten, wurden in dieser Arbeit analysiert. Detaillierte Laboruntersuchungen inklusive Gerinnungsanalysen wurden bei Aufnahme durchgefuhrt und der DIC Score berechnet. Das 28-Tage-Uberleben der Patienten wurde erhoben. Ergebnis: Hundertfunfzig Intensivstations-Aufnahmen mit Leberzirrhose wurden analysiert. Neununddreisig Prozent waren weiblich. Das mediane Alter betrug 56 (IQR 49 – 63) Jahre. Der mediane SOFA Score bei Aufnahme betrug 9 (6 – 13), der mediane MELD score 26 (IQR 18 – 36). Die 28-Tage-Mortalitat lag bei 59%. Der mediane DIC score bei Aufnahme betrug 5 (IQR 4 – 6). „Overt DIC“ (DIC Score ≥5) fand sich bei 65% der Aufnahmen. Bezogen auf die 28-Tage-Mortalitat war der DIC Score bei Nicht-Uberlebenden signifikant hoher als bei Uberlebenden (5 (IQR 4 – 7) vs. 4 (IQR 3 – 6); p < 0.01). Die AUROC fur den DIC Score hinsichtlich der Vorhersage der 28-Tage-Mortalitat war 0.68 (95% CI 0.59 – 0.77). Das Vorhandensein einer „Overt DIC“ bei Aufnahme war signifikant mit der 28-Tage-Mortalitat assoziiert (OR = 3.4 (95% CI 1.69 – 6.84), p < 0.01). Die 28-Tage-Mortalitatsrate bei Aufnahmen mit Zirrhose und „Overt DIC“ betrug 70% verglichen zu 40% bei Patienten mit einem DIC score < 5. Schlussfolgerung: Veranderungen der Hamostase finden sich in der Mehrzahl der Patienten mit Leberzirrhose auf der Intensivstation. Der DIC score ist ein Pradiktor fur das 28-Tage-Uberleben bei kritisch kranken Patienten mit Leberzirrhose.

Prediction of major bleeding in cirrhotic ICU patients using the dic score and coagulation parameters

The disseminated intravascular coagulation (DIC) score is a predictor of outcome in critically ill patients [1]. Yet, disturbances of coagulation are a common finding in patients with liver cirrhosis. Thus, the prognostic value of the DIC score and its subcomponents in patients with liver cirrhosis is unclear.