Ji-Tseng Fang

Adrenal insufficiency in patients with cirrhosis, severe sepsis and septic shock.

Patients with cirrhosis are susceptible to bacterial infection, which can result in circulatory dysfunction, renal failure, hepatic encephalopathy, and a decreased survival rate. Severe sepsis is frequently associated with adrenal insufficiency, which may lead to hemodynamic instabity and a poor prognosis. We evaluated adrenal function using short corticotropin stimulation test (SST) in 101 critically ill patients with cirrhosis and severe sepsis. Adrenal insufficiency occurred in 51.48% of patients. The patients with adrenal insufficiency had a higher hospital mortality rate when compared with those with normal adrenal function (80.76% vs. 36.7%, P < .001). The cumulative rates of survival at 90 days were 15.3% and 63.2% for the adrenal insufficiency and normal adrenal function groups, respectively (P < .0001). The hospital survivors had a higher cortisol response to corticotropin (16.2 ± 8.0 vs. 8.5 ± 5.9 μg/dL, P < .001). The cortisol response to corticotropin was inversely correlated with various disease severity, Model for End‐Stage Liver Disease, and Child–Pugh scores. Acute physiology, age, chronic health evaluation III score, and cortisol increment were independent factors to predict hospital mortality. Mean arterial pressure on the day of SST was lower in patients with adrenal insufficiency (60 ± 14 vs. 74.5 ± 13 mm Hg, P < .001), and a higher proportion of these patients required vasopressors (73% vs. 24.48%, P < .001). Mean arterial pressure, serum bilirubin, vasopressor dependency, and bacteremia were independent factors that predicted adrenal insufficiency. In conclusion, adrenal insufficiency is common in critically ill patients with cirrhosis and severe sepsis. It is related to functional liver reserve and disease severity and is associated with hemodynamic instability, renal dysfunction, and increased mortality. (HEPATOLOGY 2006;43:673–681.)

Acute kidney injury classification: comparison of AKIN and RIFLE criteria.

The Acute Kidney Injury Network (AKIN) group has recently proposed modifications to the risk of renal failure, injury to kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification system. The few studies that have compared the two classifications have revealed no substantial differences. This study aimed to compare the AKIN and RIFLE classifications for predicting outcome in critically ill patients. This retrospective study investigated the medical records of 291 critically ill patients who were treated in medical intensive care units of a tertiary care hospital between March 2003 and February 2006. This study compared performance of the RIFLE and AKIN criteria for diagnosing and classifying AKI and for predicting hospital mortality. Overall mortality rate was 60.8% (177/291). Increased mortality was progressive and significant (chi-square for trend; P < 0.001) based on the severity of AKIN and RIFLE classification. Hosmer and Lemeshow goodness-of-fit test results demonstrated good fit in both systems. The AKIN and RIFLE scoring systems displayed good areas under the receiver operating characteristic curves (0.720 ± 0.030, P = 0.001; 0.738 ± 0.030, P = 0.001, respectively). Compared with RIFLE criteria, this study indicated that AKIN classification does not improve the sensitivity and ability of outcome prediction in critically ill patients.

Prognosis of Patients on Extracorporeal Membrane Oxygenation: The Impact of Acute Kidney Injury on Mortality

BACKGROUND Extracorporeal membrane oxygenation (ECMO) has been utilized for patients in critical condition, such as those with life-threatening respiratory failure or postcardiotomy cardiogenic shock. This study analyzed the outcomes of patients treated with ECMO and identified the relationship between prognosis and the Acute Kidney Injury Network (AKIN) scores obtained at pre-ECMO support (AKIN0-hour); and at post-ECMO support 24 hours (AKIN24-hour) and 48 hours (AKIN48-hour). METHODS This study reviewed the medical records of 102 critically ill patients on ECMO support at a specialized intensive care unit at a tertiary care university hospital between March 2002 and January 2008. Demographic, clinical, and laboratory variables were retrospectively collected as survival predicators. RESULTS The overall mortality rate was 57.8%. The most common condition requiring ECMO support was cardiogenic shock. Goodness-of-fit was good for AKIN0-hour, AKIN24-hour, and AKIN48-hour criteria. The AKIN0-hour, AKIN24-hour, and AKIN48-hour scoring systems also had excellent areas under the receiver operating characteristic curve (0.804±0.046, 0.811±0.045, and 0.858±0.040, respectively). Furthermore, multiple logistic regression analysis indicated that AKIN48-hour, age, and Glasgow Coma Scale score on the first day of intensive care unit admission were independent risk factors for hospital mortality. Finally, cumulative survival rates at 6-month follow-up after hospital discharge differed significantly (p<0.05) for AKIN48-hour stage 0 versus AKIN48-hour stages 1, 2, and 3; and AKIN48-hour stage 1 and 2 versus AKIN48-hour stage 3. CONCLUSIONS During ECMO support, the AKIN48-hour scoring system proved to be a reproducible evaluation tool with excellent prognostic abilities for these patients.

Comparison of the severity of illness scoring systems for critically ill cirrhotic patients with renal failure

BACKGROUND Mortality rates of cirrhotic patients with renal failure admitted to the medical intensive care unit (ICU) are high. End-stage liver disease is frequently complicated by disturbances of renal function. This investigation is aimed to compare the predicting ability of acute physiology, age, chronic health evaluation II and III (APACHE II and III), sequential organ failure assessment (SOFA), and Child-Pugh scoring systems, obtained on the first day of ICU admission, for hospital mortality in critically ill cirrhotic patients with renal failure. METHODS Sixty-seven patients with liver cirrhosis and renal failure were admitted to ICU from April 2001-March 2002. Information considered necessary for computing the Child-Pugh, SOFA, APACHE II and APACHE III score on the first day of ICU admission was prospectively collected. RESULTS The overall hospital mortality rate was 86.6%. Liver disease was most commonly attributed to hepatitis B viral infection. The development of renal failure was associated with a history of gastrointestinal bleeding. Goodness-of-fit was good for SOFA, APACHE II and APACHE III scores. The APACHE III and SOFA models reported good areas under receiver operating characteristic curve (0.878 +/- 0.050 and 0.868 +/- 0.051, respectively). CONCLUSION Renal failure is common in critically ill patients with cirrhosis. The prognosis for cirrhotic patients with renal failure is poor. APACHE III and SOFA showed excellent discrimination power in this group of patients. They are superior to APACHE II and Child-Pugh scores in this homogenous group of patients.

RIFLE CLASSIFICATION FOR PREDICTING IN-HOSPITAL MORTALITY IN CRITICALLY ILL SEPSIS PATIENTS

Severe sepsis and septic shock, often complicated by acute kidney injury (AKI), are the most common causes of mortality in noncoronary intensive care units (ICUs). This study investigates the outcomes of critically ill patients with sepsis and elucidates the association between prognosis and risk of renal failure, injury to the kidney, failure of kidney function, loss of kidney function, and end-stage renal failure (RIFLE) classification. A total of 121 sepsis patients were admitted to ICU from June 2003 to January 2004. Forty-seven demographic, clinical, and laboratory variables were prospectively recorded for post hoc analysis as predictors of survival on the first day of ICU admission. Overall in-hospital mortality rate was 47.9%. Mortality was significantly associated (chi-square for trend; P < 0.001) with RIFLE classification. Septic shock, RIFLE category, and number of organ system failures on the first day of ICU admission were independent predictors of hospital mortality according to forward conditional logistic regression. The severity of RIFLE classification correlated with organ system failure number and Acute Physiology and Chronic Health Evaluation (APACHE) II to IV and sequential organ failure assessment scores. Cumulative survival rates at 6-month follow-up after hospital discharge significantly (P < 0.05) differed between non-AKI versus RIFLE injury, non-AKI versus RIFLE failure (RIFLE-F), and RIFLE risk versus RIFLE F. At 6-month follow-up, full recovery of renal function was noted in 85% of surviving patients with AKI (RIFLE risk, RIFLE injury, and RIFLE-F). In conclusion, these findings are consistent with a role for RIFLE classification in accurately predicting in-hospital mortality and short-term prognosis in ICU sepsis patients.

Multiple Organ System Failure in Critically Ill Cirrhotic Patients

Objectives: The prognosis for critically ill cirrhotic patients depends on the extent of hepatic and extrahepatic organ dysfunction/failure. We hypothesize that a graded multiple organ dysfunction score, sequential organ failure assessment (SOFA), would provide more descriptive and discriminative power for predicting the hospital mortality for critically ill cirrhotic patients than the classical organ system failure (OSF) score, which defines organ failure as an all-or-none phenomenon. Methods: 160 patients diagnosed with liver cirrhosis were admitted to the medical intensive care unit (ICU) from January 2002 to June 2003. Information considered necessary for calculating the Child-Pugh, OSF and SOFA scores on ICU admission was collected prospectively. Results: Hepatitis B infection was the most common cause of liver cirrhosis. A significantly progressive increase in mortality rate was associated with OSF and SOFA scores (p < 0.001). Close correlation between OSF and SOFA scores (p < 0.001) suggested that both systems evaluated the same event. In patients with similar organ dysfunction, the number of failed organ system(s) was significantly higher among non-survivors. However, no correlation existed between the SOFA scores and mortality rate in patients with the same OSF number. Meanwhile, both OSF and SOFA scores displayed excellent discriminative power (areas under receiver-operating characteristic (AUROC) were 0.906 and 0.892, respectively), while Child-Pugh scores clearly performed more poorly (AUROC 0.712). Both OSF and SOFA demonstrate a good fit using the Hosmer and Lemeshow goodness-of-fit test. Conclusions: Both OSF and SOFA scores are excellent tools for predicting prognosis for cirrhotic patients admitted to ICU. Both of them are superior to Child-Pugh score. Hospital mortality for critically ill cirrhotic patients occurs owing to severe failure of a relatively few organs, rather than because of an accumulation of mild dysfunction in many organ systems. Graded organ dysfunction scales provide no further benefit for predicting hospital mortality for critically ill cirrhotic patients.

Serum Sodium Predicts Prognosis in Critically Ill Cirrhotic Patients

Background End-stage liver disease is often complicated by hyponatremia. Cirrhotic patients with hyponatremia admitted to intensive care units (ICUs) have high mortality rates. This study analyzed the outcomes of critically ill cirrhotic patients and identified the prognostic value of serum sodium concentration. Methods One hundred twenty-six consecutive cirrhotic patients admitted to the ICU of a tertiary center during a 1.5-year period were enrolled in this study. Demographic, clinical, and laboratory variables on the first day of ICU admission were prospectively recorded for post hoc analysis. Results Overall hospital mortality was 65.1%. Comparing with serum sodium >135 mmol/L, patients with serum sodium ≤135 mmol/L had a greater frequency of ascites, illness severity scores, hepatic encephalopathy, sepsis, renal failure, and in-hospital mortality (55.9% vs. 73.1%, P=0.043). Multiple Cox proportional hazards analysis revealed that serum sodium levels, hepatocellular carcinoma, and sequential organ failure assessment scores on the first day of ICU admission were independent risk factors for 6-month mortality. Cumulative survival rates at 6-month follow-up after hospital discharge differed significantly (P<0.05) between patients with serum sodium >135 mmol/L versus those with serum sodium ≤135 mmol/L. Conclusions Low serum sodium levels in critically ill cirrhotic patients are associated with high complications of liver cirrhosis, in-hospital mortality, and poor short-term prognosis. The serum sodium concentration is important predictor of survival among candidates for liver transplantation. Future research with sequential application of serum sodium may reflect the dynamic aspects of clinical conditions, thus providing complete data for mortality risk.

Outcome predictors and new score of critically ill cirrhotic patients with acute renal failure

BACKGROUND End-stage liver disease is often complicated by renal function disturbances. Cirrhotic patients with acute renal failure admitted to intensive care units (ICUs) have high mortality rates. This work seeks to identify specific predictors of hospital mortality in critically ill cirrhotic patients with acute renal failure. METHODS A total of 111 patients with cirrhosis and acute renal failure were admitted to ICU from March 2003 to February 2005. Twenty-six demographic, clinical and laboratory variables were prospectively gathered as predictors of survival on the first day of ICU admission. RESULTS The overall hospital mortality rate was 81.1%. The univariate analysis identified 11 of the 32 variables as prognostically valuable. The multiple logistic regression analysis (excluding five scoring systems) indicates that the mean arterial pressure (MAP), serum bilirubin, respiratory failure and sepsis on the first day in ICU are significantly related to prognosis. The best Youden index (sensitivity + specificity - 1) yields cutoff points of 80 MAP (in mmHg) and 80 serum bilirubin (in micromol/L) (or 4.7 mg/dL) and indicates acute respiratory failure and sepsis. A simple model for mortality is developed on the basis of these four readily available parameters on Day 1 of ICU admission. The new score (MBRS score: MAP + bilirubin + respiratory failure + sepsis) displays an excellent area under the receiver operating characteristic curve (0.898 +/- 0.031, P < 0.001). The mortality rate exceeds 90% when the MBRS (MAP + bilirubin + respiratory failure + sepsis) score is 2 or higher. CONCLUSION The MBRS score is a straightforward, reproducible and easily adopted evaluative tool with good prognostic abilities, which generates objective data for patient families and physicians and supplements a clinical judgment of prognosis.

Prospective cohort study comparing sequential organ failure assessment and acute physiology, age, chronic health evaluation III scoring systems for hospital mortality prediction in critically ill cirrhotic patients

The aim of the study was to evaluate the usefulness of sequential organ failure assessment (SOFA) and acute physiology, age, chronic health evaluation III (APACHE III) scoring systems obtained on the first day of intensive care unit (ICU) admission in predicting hospital mortality in critically ill cirrhotic patients. The study enrolled 102 cirrhotic patients consecutively admitted to ICU during a 1‐year period. Twenty‐five demographic, clinical and laboratory variables were analysed as predicators of survival. Information considered necessary to calculate the Child–Pugh, SOFA and APACHE III scores on the first day of ICU admission was also gathered. Overall hospital mortality was 68.6%. Multiple logistic regression analysis revealed that mean arterial pressure, SOFA and APACHE III scores were significantly related to prognosis. Goodness‐of‐fit was good for the SOFA and APACHE III models. Both predictive models displayed a similar degree of the best Youden index (0.68) and overall correctness (84%) of prediction. The SOFA and APACHE III models displayed good areas under the receiver–operating characteristic curve (0.917 ± 0.028 and 0.912 ± 0.029, respectively). Finally, a strong and significant positive correlation exists between SOFA and APACHE III scores for individual patients (r2 = 0.628, p < 0.001). This investigation confirms the grave prognosis for cirrhotic patients admitted to ICU. Both SOFA and APACHE III scores are excellent tools to predict the hospital mortality in critically ill cirrhotic patients. The overall predictive accuracy of SOFA and APACHE III is superior to that of Child–Pugh system. The role of these scoring systems in describing the dynamic aspects of clinical courses and allocating ICU resources needs to be clarified.

Low serum concentration of apolipoprotein A-I is an indicator of poor prognosis in cirrhotic patients with severe sepsis

BACKGROUND/AIMS Severe sepsis is frequently associated with hypocholesterolemia which is also a common finding in cirrhotic patients. Lipoprotein is capable of binding endotoxin to which cirrhotic patients exhibit an excessive pro-inflammatory response. METHODS We evaluated the relationship between lipid levels, inflammatory cytokines and clinical outcomes in 103 cirrhotic patients with severe sepsis. RESULTS The non-survivors had significantly lower concentrations of total cholesterol, high-density lipoprotein (HDL), and apolipoprotein A-I (APO A-I). HDL and APO A-I levels were inversely correlated with interleukin-6, tumor necrosis factor-alpha, and various disease severity scores. Serum creatinine, mean arterial pressure and low level of APO A-I (<47.5mg/dl) were independent factors to predict 90-day mortality. The cumulative survival rates at 90 days were 63.8% and 8.9% for the high APO A-I and low APO A-I groups (p<0.0001). Low APO A-I was also associated with lower mean arterial pressure, higher rate of vasopressor dependency, and greater plasma renin activity. CONCLUSIONS Serum levels of HDL and APO A-I are inversely correlated with liver reserve and disease severity in cirrhotic patients with severe sepsis. Low level of APO A-I is associated with a marked impairment of effective arterial volume, multiple organ dysfunction and a poor prognosis.