|
1
|
Soni JR, Marrapu S, Kumar R. Hypochloremia is an underutilised prognostic marker in patients with advanced liver cirrhosis and liver failure. World J Hepatol 2025; 17:103807. [PMID: 40177202 PMCID: PMC11959668 DOI: 10.4254/wjh.v17.i3.103807] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2024] [Revised: 02/16/2025] [Accepted: 02/27/2025] [Indexed: 03/26/2025] Open
Abstract
Patients with advanced liver cirrhosis and liver failure frequently experience abnormalities in their serum electrolyte levels. In such patients, hyponatremia has been identified as a predictor of poor outcomes. However, emerging evidence suggests that serum chloride may provide even better prognostic information in similar situations. Hypochloremia, characterised by low serum chloride levels, has been linked to increased mortality, exacerbated organ dysfunction, and higher requirements for renal replacement therapy and vasopressors in various critical conditions, including advanced liver diseases. The pathophysiological mechanisms underlying the association between low serum chloride levels and poor outcomes in liver disease appear to involve complex interactions among electrolyte imbalances, renal function, and systemic hemodynamics. Chloride dysregulation can influence renal salt-sensing mechanisms, disrupt acid-base homeostasis, and exacerbate complications such as hepatic encephalopathy and hepatorenal syndrome. This article aims to elucidate the prognostic significance of lower serum chloride levels in patients with advanced liver disease. By reviewing recent literature and analysing clinical data, we seek to establish serum chloride as an underutilised but valuable prognostic marker. Understanding the role of serum chloride in liver disease could enhance prognostic accuracy, refine treatment strategies, and ultimately improve patient outcomes.
Collapse
Affiliation(s)
- Jinit R Soni
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
| | - Sudheer Marrapu
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna 801507, India.
| |
Collapse
|
|
2
|
Wang J, Chen X, Qin C, Shi R, Huang Y, Gong J, Zeng X, Wang D. Lactate-to-albumin ratio as a potential prognostic predictor in patients with cirrhosis and sepsis: a retrospective cohort study. BMC Infect Dis 2025; 25:223. [PMID: 39953385 PMCID: PMC11829571 DOI: 10.1186/s12879-025-10601-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2024] [Accepted: 02/04/2025] [Indexed: 02/17/2025] Open
Abstract
BACKGROUND Patients with liver cirrhosis face high infection risks due to immune dysfunction and hospital-related factors, increasing mortality rates when sepsis occurs. While various biomarkers predict outcomes in cirrhosis, few are accessible and reliable. This study addresses the gap by evaluating the prognostic potential of the lactate-to-albumin ratio (LAR). METHODS We retrospectively analyzed data from patients with cirrhosis and sepsis who were admitted to the intensive care unit at Beth Israel Deaconess Medical Center between 2008 and 2022. LAR was calculated from the ratio obtained from the first measurement taken within 24 h of admission. The optimal LAR threshold was determined using R statistical software. Kaplan-Meier analysis was used to compare mortality risks between two patient groups, while multivariate Cox proportional hazards regression models were used to assess the association between LAR and mortality risk in patients with cirrhosis and concomitant sepsis. A restricted cubic spline (RCS) was used to explore potential dose-response relationships between LAR and mortality. Receiver operating characteristic (ROC) analyses were used to assess the predictive ability, sensitivity, and specificity of LAR for all-cause mortality in patients with cirrhosis and combined sepsis, and the area under the curve (AUC) was calculated. Finally, subgroup analyses were performed to assess the relationship between LAR and prognosis across different populations. RESULTS A total of 1731 patients were included in the study. The optimal LAR threshold was identified as 1.0 using R statistical software. Kaplan-Meier analysis indicated that patients with higher LAR levels had a higher risk of 14-day, 28-day, and 90-day all-cause mortality (all log-rank P < 0.001). Multivariate Cox proportional hazards models indicated independent associations between higher LAR levels and all-cause mortality at 14-day, 28-day, and 90-day before and after adjusting for confounders. RCS analysis revealed a nonlinear association between LAR and short- and long-term all-cause mortality in patients with cirrhosis and sepsis. ROC curve analysis showed that although the predictive value of LAR for the prognosis of patients with cirrhosis combined with sepsis was slightly inferior to that of the Model for End-Stage Liver Disease score, it was significantly better than that of lactate, albumin, and the Sequential Organ Failure Assessment. Subgroup analyses showed no significant interactions between LAR and any specific subgroup. CONCLUSION LAR has good predictive value for the prognosis of patients with cirrhosis and sepsis.
Collapse
Affiliation(s)
- Jianjun Wang
- Department of Hepatobiliary Surgery, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, China
- NHC Key Laboratory of Nuclear Technology Medical Transformation, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Xi Chen
- Department of Hepatobiliary Surgery, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Chuan Qin
- Department of Hepatobiliary Surgery, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Ruizi Shi
- Department of Hepatobiliary Surgery, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Yu Huang
- Department of Hepatobiliary Surgery, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, China
| | - Jianping Gong
- The Second Affiliated Hospital of Chongqing Medical University, Chongqing, 400010, China.
| | - Xintao Zeng
- Department of Hepatobiliary Surgery, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, China.
| | - Decai Wang
- NHC Key Laboratory of Nuclear Technology Medical Transformation, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, China.
- Department of Urology, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, 621000, China.
| |
Collapse
|
|
3
|
Aggarwal A, Biswas S, Arora U, Vaishnav M, Shenoy A, Swaroop S, Agarwal A, Elhence A, Kumar R, Goel A, Shalimar. Definitions, Etiologies, and Outcomes of Acute on Chronic Liver Failure: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2024; 22:2199-2210.e25. [PMID: 38750869 DOI: 10.1016/j.cgh.2024.04.018] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is a major public health concern. We aimed to assess the definitions, etiologic spectrum, organ failure (OF), and outcomes of ACLF globally. METHODS Three databases were searched for studies on ACLF from 1990 until September 2022. Information regarding definitions, acute precipitants, underlying chronic liver disease (CLD), OF, and mortality were extracted. Meta-analyses were performed for pooled prevalence rates (95% confidence interval [CI]) using random-effects model for each definition of ACLF. RESULTS Of the 11,451 studies identified, 114 articles (142 cohorts encompassing 210,239 patients) met the eligibility criteria. Most studies (53.2%) used the European Association for the Study of the Liver (EASL) definition, followed by Asia-Pacific Association for the Study of the Liver (APASL) (33.3%). Systemic infection was the major acute precipitant, and alcohol use was the major cause of CLD in EASL-defined studies, whereas alcohol was both the major acute precipitant and cause of CLD in APASL-defined studies. Liver failure was the major OF in APASL-based studies, whereas renal failure was predominant in EASL-based studies. Thirty-day mortality varied across definitions: APASL: 38.9%, 95% CI, 31.2%-46.9%; EASL: 47.9%, 95% CI, 42.2%-53.5%; and NACSELD: 52.2%, 95% CI, 51.9%-52.5%. Diagnostic overlap between definitions ranged from 7.7% to 80.2%. Meta-regression suggested that the World Health Organization region influenced 30-day mortality in studies using EASL definition. CONCLUSIONS Heterogeneity in the definition of ACLF proposed by different expert societies and regional preferences in its use result in differences in clinical phenotype and outcomes. A uniform definition would enhance the comparability and interpretation of global data.
Collapse
Affiliation(s)
- Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Abhishek Shenoy
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Ayush Agarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Amit Goel
- Department of Hepatology, Sanjay Gandhi Institute of Medical Sciences, Lucknow, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India.
| |
Collapse
|
|
4
|
Pan Z, Lin J, Huo C, Yin D, Guo Q. Increased serum albumin corrected anion gap levels are associated with poor prognosis in septic patients with liver cirrhosis. Sci Rep 2024; 14:21510. [PMID: 39277682 PMCID: PMC11401841 DOI: 10.1038/s41598-024-72703-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2024] [Accepted: 09/10/2024] [Indexed: 09/17/2024] Open
Abstract
The prognosis of septic patients with cirrhosis is worse compared to septic patients without cirrhosis. Early and accurate prognosis determination in patients with cirrhosis and sepsis is pivotal for guiding treatment decisions. The aim of this study was to investigate the association between albumin-corrected anion gap (ACAG) and clinical prognosis of patients with sepsis and cirrhosis. This study extracted data of patients with sepsis and cirrhosis from the Medical Information Mart for Intensive Care (MIMIC-IV) database. A total of 1340 patients (64.6% male) were enrolled. After confounders adjusting, elevated ACAG had a significant association with 28-day mortality (HR1.604; 95% CI 1.258-2.048; P < 0.001). Restricted cubic spline revealed that a linear relationship between ACAG and 28-day mortality (P-nonlinear = 0.089, P-overall = 0.001). According to the ROC curve analysis, the ACAG demonstrated a higher area under the curve (AUC) of 0.703 compared to AG (0.675). Kaplan-Meier analysis revealed higher 28-day mortality in high ACAG group (log-rank test, χ^2 = 175.638, P < 0.001). Furthermore, subgroup analysis showed a significant interaction between ACAG and etiology of cirrhosis (P for interaction = 0.014). Therefore, ACAG could provide clinicians with valuable insights for guiding interventions in this high-risk population.
Collapse
Affiliation(s)
- Zetao Pan
- Department of Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
| | - Jiancheng Lin
- Department of Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
| | - Cunyang Huo
- Department of Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
| | - Di Yin
- Department of Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China
| | - Qiang Guo
- Department of Critical Care Medicine, The Fourth Affiliated Hospital of Soochow University (Suzhou Dushu Lake Hospital), Suzhou, Jiangsu, China.
- Department of Emergency and Critical Care Medicine, The First Affiliated Hospital of Soochow University, Suzhou, Jiangsu, China.
| |
Collapse
|
|
5
|
Braun G. [Ethical aspects regarding the management of patients with liver disease in the intensive care unit]. Med Klin Intensivmed Notfmed 2024; 119:478-483. [PMID: 39134715 DOI: 10.1007/s00063-024-01165-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2024] [Revised: 05/27/2024] [Accepted: 06/05/2024] [Indexed: 08/22/2024]
Abstract
BACKGROUND Especially in terms of alcohol-related liver cirrhosis, discussions quickly arise in times of scarce resources about the justification for carrying out (prolonged) intensive care measures. AIMS, MATERIALS, AND METHODS The following review aims to address ethical aspects specifically in patients with liver cirrhosis in the intensive care unit. A possible structured approach is presented. CONCLUSION A general recommendation is not possible. Ultimately, decisions remain on a case-by-case basis and have to take a wide variety of perspectives into account.
Collapse
Affiliation(s)
- Georg Braun
- Internistische Intensivstation IZ1.1, Medizinische Klinik 3, Universitätsklinikum Augsburg, Stenglinstr. 2, 86156, Augsburg, Deutschland.
| |
Collapse
|
|
6
|
Kou Y, Du S, Zhang M, Nie B, Yuan W, He K, Qin L, Ye S, Yang Y. Serum Anion Gap at Admission Predicts All-Cause Mortality in Critically Ill Patients With Cirrhosis: A Retrospective Cohort Study. Clin Transl Gastroenterol 2024; 15:e1. [PMID: 38920294 PMCID: PMC11421715 DOI: 10.14309/ctg.0000000000000734] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2023] [Accepted: 06/12/2024] [Indexed: 06/27/2024] Open
Abstract
INTRODUCTION The primary objective of this study was to evaluate admission serum anion gap (AG) as a predictor of all-cause mortality in critically ill patients with cirrhosis. METHODS A total of 3,084 cirrhotic patients were included and randomly divided into training and validation cohorts (n = 2,159 and 925, respectively). Patients were categorized into high and normal AG groups based on their AG values. Cox regression and Kaplan-Meier survival analysis were used to assess the relationships between AG levels and outcomes. RESULTS Both cohorts showed strong parameter similarity ( P > 0.05). High AG was associated with significantly lower survival probabilities. Cox models confirmed elevated AG as a risk factor, even after adjusting for covariates (hazard ratio: 1.920, 1.793, and 1.764 for 30-day, 60-day, and hospital mortality, respectively). Subgroup analyses, especially regarding chronic kidney disease, revealed complex interactions. Serum AG displayed predictive power comparable with established scoring systems. DISCUSSION Elevated AG at admission is a valuable predictor of poor outcomes and increased mortality risk in critically ill cirrhotic patients. Serum AG can serve as an easily accessible tool for risk assessment and prognosis evaluation in this population.
Collapse
Affiliation(s)
- Yanqi Kou
- Department of Gastroenterology, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, Zhanjiang City, China
- Department of Hematology, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Shenshen Du
- Department of Gastroenterology, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, Zhanjiang City, China
- Department of Gastroenterology, Huanghe Sanmenxia Hospital, Sanmenxia, China
| | - Mingcheng Zhang
- Department of Gastroenterology, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, Zhanjiang City, China
| | - Biao Nie
- Department of Gastroenterology, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, China
| | - Weinan Yuan
- Department of Gastroenterology, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, Zhanjiang City, China
- Department of Gastroenterology, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, China
| | - Kun He
- Department of Gastroenterology, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, Zhanjiang City, China
- Department of Gastroenterology, The First Affiliated Hospital of Jinan University, Jinan University, Guangzhou, China
| | - Ling Qin
- Department of Hematology, The First Affiliated Hospital, and College of Clinical Medicine of Henan University of Science and Technology, Luoyang, China
| | - Shicai Ye
- Department of Gastroenterology, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, Zhanjiang City, China
| | - Yuping Yang
- Department of Gastroenterology, Affiliated Hospital of Guangdong Medical University, Guangdong Medical University, Zhanjiang City, China
| |
Collapse
|
|
7
|
Liu H, Cao Y, Xue X, Bai Z, Wu S. Clinical efficacy of sodium bicarbonate in treating pediatric metabolic acidosis with varying level of acid-base balance parameters: a real-world study. BMC Med 2023; 21:473. [PMID: 38031038 PMCID: PMC10688456 DOI: 10.1186/s12916-023-03189-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 11/21/2023] [Indexed: 12/01/2023] Open
Abstract
BACKGROUND Sodium bicarbonate (SB) infusion is commonly used to correct metabolic acidosis, but its clinical efficacy remains controversial. This study aims to investigate whether acid-base balance parameters should be a consideration for administering SB treatment. METHODS Children with metabolic acidosis (pH < 7.35 and bicarbonate < 22 mmol/L) who were treated with or without 50 mg/ml SB injection were grouped and extracted from a retrospective cohort database of the Pediatric Intensive Care Unit. The interaction between acid-base balance parameters and SB treatment on mortality was analyzed through mortality curves and cross-effect models. Logistic regression was conducted to estimate the risk of death following SB treatment in the overall children as well as in subgroups, and potential confounding factors were adjusted for. After employing propensity score matching to account for confounding factors, further analysis was performed to evaluate the effectiveness of SB treatment within each chloride subgroup. RESULTS A total of 5865 children with metabolic acidosis were enrolled, of which 2462 (42.0%) received SB treatment. In the overall population, it was found that SB treatment did not reduce hospital mortality or 28-day mortality. Interactions between acid-base balance parameters (chloride and anion gap) and SB treatment on mortality were observed. Subgroup analysis clarified that when chloride levels were below 107 mmol/L, children treated with SB had higher in-hospital mortality (29.8% vs 14.9%) and 28-day mortality (26.5% vs 13.4%), with adjusted ORs of 2.065 (95% CI, 1.435-2.97) and 1.947 (95% CI, 1.332-2.846), respectively. In contrast, when chloride levels were greater than or equal to 113 mmol/L, children treated with SB had a shorter stay in the PICU (median: 1.1 days vs 5.1 days, adjusted p = 0.004) and lower in-hospital mortality (4.3% vs 10.3%) and 28-day mortality (4.0% vs 8.4%), with adjusted ORs of 0.515 (95% CI, 0.337-0.788) and 0.614 (95% CI, 0.391-0.965), respectively. After controlling for confounding factors through matching, the impact of SB treatment on the risk of death in each chloride subgroup was consistent with the aforementioned results. However, treatment with SB did not significantly increase the risk of death in newborns or children with moderate to severe metabolic acidosis when chloride levels were below 107 mmol/L (p > 0.05). CONCLUSIONS The use of sodium bicarbonate for treating metabolic acidosis has been found to increase mortality in children with low chloride levels but decrease mortality in those with high chloride levels in this study. Further prospective multi-center clinical studies and basic research are needed to validate these findings.
Collapse
Affiliation(s)
- Huaqing Liu
- Health Supervision Institute of Gusu District, Suzhou, 215000, Jiangsu, China
| | - Yanmei Cao
- Department of Occupational Disease Medicine, The Fifth People's Hospital of Suzhou, The Affiliated Infectious Diseases Hospital of Soochow University, No.10, Guangqian Road, Suzhou, 215131, China
| | - Xiaoyan Xue
- People's Hospital of Ganzhou, Ganzhou, 341200, Jiangxi, China
| | - Zhenjiang Bai
- Pediatric Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, 215000, Jiangsu, China.
| | - Shuiyan Wu
- Pediatric Intensive Care Unit, Children's Hospital of Soochow University, Suzhou, 215000, Jiangsu, China.
| |
Collapse
|
|
8
|
Chandra S, Ravula S, Errabelli P, Spencer H, Singh M. No Good Deed: Acidosis in Chronic Kidney and Liver Disease. J Ren Nutr 2023; 33:499-502. [PMID: 36736470 DOI: 10.1053/j.jrn.2022.12.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 11/09/2022] [Accepted: 12/13/2022] [Indexed: 02/05/2023] Open
Abstract
OBJECTIVE Studies have shown that low or high serum bicarbonate levels (reflecting metabolic acidosis or alkalosis) are associated with increased all-cause mortality rates in moderate and advanced chronic kidney disease (CKD) cases. Correction of presumed acidosis using sodium bicarbonate, targeting serum levels around 22 mmol/L, has proven to be beneficial in delaying the progression of the disease and provided mortality benefit. A similar prognostic association may exist between uncorrected metabolic acidosis in chronic liver disease. Correcting it with sodium-containing salts may require more interventions due to increased sodium/fluid load. In patients with liver failure, a naturally alkalotic state, where sodium load is a concern, the impact of this intervention is unclear. DESIGN This study aims to generate proof of concept through a retrospective chart review in individuals with CKD-related metabolic acidosis and liver cirrhosis. RESULT Our analysis revealed a statistically significant association between the need for paracentesis and bicarbonate therapy. Our study has multiple drawbacks, including a retrospective chart review and limitation of data due to single-center patients. CONCLUSION We extrapolate that lowering bicarbonate targets in other clinical scenarios like liver failure, pregnancy, and cardiac failure may be prudent and will lead to a lower sodium load.
Collapse
Affiliation(s)
- Samira Chandra
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | | | | | - Horace Spencer
- University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Manisha Singh
- University of Arkansas for Medical Sciences, Little Rock, Arkansas.
| |
Collapse
|
|
9
|
Ji X, Peng S. The association between serum anion gap and all-cause mortality of unselected adult patients: A retrospective cohort study of >20,000 patients. J Clin Lab Anal 2023; 37:e24818. [PMID: 36550640 PMCID: PMC9833973 DOI: 10.1002/jcla.24818] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2022] [Revised: 11/25/2022] [Accepted: 12/07/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Even though the serum anion gap (AG) is frequently measured in clinical practice, there is not much research that has examined long-term mortality in unselected adult patients. Our study's objective was to investigate how serum anion gap levels could be used to predict death in unselected participants. METHODS The relationship between baseline serum AG levels and short-, intermediate-, and long-term all-cause mortality in unselected adult patients is examined using the Cox proportional risk analysis, smoothed curve fitting, subgroup analysis, and Kaplan-Meier survival curves. RESULTS After screening the database using the appropriate method, a total of 26,270 patients were enrolled in our study for the final data analysis. Our study used smoothed curve fit plots and COX proportional risk regression models incorporating cubic spline functions to evaluate the association between AG levels and all-cause mortality in a non-selected population, and the results indicated a non-linear relationship. In the fully adjusted model, we found that AG levels were positively associated with 30-day, 90-day, 365-day, and 4-year all-cause mortality in unselected adult patients with HRs of 1.08 95% CIs (1.06, 1.09); 1.08 95% CIs (1.06, 1.09); 1.08 95% CIs (1.07, 1.08); 1.07 95% CIs (1.06, 1.07). CONCLUSION Serum anion gap levels were positively correlated with all-cause mortality in unselected adult patients, with increasing levels of serum anion gap increasing patient mortality.
Collapse
Affiliation(s)
- Xuan Ji
- Department of Traditional Chinese Medicine, The First Affiliated Hospital of Shantou University Medical College, Shantou, China
| | - Shixuan Peng
- Department of Oncology, Graduate Collaborative Training Base of The First People's Hospital of Xiangtan City, Hengyang Medical school, University of South China, Hengyang, China
| |
Collapse
|
|
10
|
Characteristics and predictors of short-term mortality in decompensated cirrhotic patients with acute-on-chronic liver failure. Clin Exp Hepatol 2022; 8:300-308. [PMID: 36683875 PMCID: PMC9850305 DOI: 10.5114/ceh.2022.122332] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2022] [Accepted: 09/28/2022] [Indexed: 12/31/2022] Open
Abstract
Aim of the study We aimed to investigate the characteristics of acute-on-chronic liver failure (ACLF) and factors associated with 28-day mortality in patients with ACLF. Material and methods This prospective study included ACLF patients based on the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) Consortium criteria, admitted between March 2021 and February 2022. We examined variables associated with 28-day mortality using multivariate Cox regression analysis. Results Of 326 patients admitted with acute decompensation (AD) of cirrhosis, 109 (33.44%) patients were diagnosed with ACLF (mean age 63.61 ±11.15 years, 65.14% males). Of these, 26.61%, 35.78%, and 37.61% of patients were in ACLF grades 1, 2, and 3 respectively. HCV (80.73%) was the main aetiology of cirrhosis. Upper gastrointestinal bleeding (25.69%) was the most common trigger. Kidney failure (73.39%) was the most common organ failure. The 28-day mortality rate was 66.97%. Cox regression analysis revealed that the existence of 2 (HR = 6.99, 95% CI: 2.68-18.25, p < 0.0001) or ≥ 3 (HR = 9.34, 95% CI: 3.6-24.74, p < 0.0001) organ failures, hepatic encephalopathy (HR = 2.96, 95% CI: 1.27-6.94, p = 0.01), and elevated serum bilirubin (HR = 1.03, 95% CI: 1.00-1.06, p = 0.04) were independent predictors for 28-day mortality, while shifting blood pH to the normal range was associated with a decrease in the HR of ACLF mortality (HR = 0.03, 95% CI: 0.002-0.44, p = 0.01). Conclusions ACLF has a very high 28-day mortality, which is associated with the existence of 2 or more organ failures, hepatic encephalopathy, elevated serum bilirubin, and low blood pH.
Collapse
|
|
11
|
Katopodis P, Pappas EM, Katopodis KP. Acid-base abnormalities and liver dysfunction. Ann Hepatol 2022; 27:100675. [PMID: 35074477 DOI: 10.1016/j.aohep.2022.100675] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/10/2021] [Revised: 01/14/2022] [Accepted: 01/15/2022] [Indexed: 02/04/2023]
Abstract
In addition to the kidneys and lungs, the liver also plays an important role in the regulation of the Acid-Base Equilibrium (ABE). The involvement of the liver in the regulation of ABE is crucial because of its role in lactic acid metabolism, urea production and in protein homeostasis. The main acid-base imbalance that occurs in patients with liver cirrhosis is Respiratory Alkalosis (RAlk). Due to the fact that in these patients additional pathophysiological mechanisms that affect the ABE are present, other disorders may appear which compensate or enhance the primary disorder. Conventional ABE reading models fail to identify and assess the underlying disorders in patients with liver cirrhosis. This weakness of the classical models led to the creation of new physicochemical mathematical models that take into account all the known parameters that develop and affect the ABE. In addition to the RAlk, in patients with liver cirrhosis, metabolic alkalosis (due to hypoalbuminemia), hyponatremic metabolic acidosis, hyperchloremic metabolic acidosis, lactic acidosis and metabolic alkalosis due to urea metabolism are some of the pathophysiological mechanisms that affect the ABE.
Collapse
Affiliation(s)
- Periklis Katopodis
- Biosciences, College of Health, Medicine and Life Sciences, Brunel University London, Uxbridge, UK.
| | | | | |
Collapse
|
|
12
|
Kim KS, Lee SH, Sang BH, Hwang GS. Intraoperative lactic acid concentration during liver transplantation and cutoff values to predict early mortality: a retrospective analysis of 3,338 cases. Anesth Pain Med (Seoul) 2021; 17:213-220. [PMID: 34974648 PMCID: PMC9091666 DOI: 10.17085/apm.21056] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2021] [Accepted: 09/10/2021] [Indexed: 11/17/2022] Open
Abstract
Background We aimed to explore the distribution of intraoperative lactic acid (LA) level during liver transplantation (LT) and determine the optimal cutoff values to predict post-LT 30-day and 90-day mortality. Methods Intraoperative LA data from 3,338 patients were collected between 2008 to 2019 and all-cause mortalities within 30 and 90 days were retrospectively reviewed. Of the three LA levels measured during preanhepatic, anhepatic, and neohepatic phase of LT, the peak LA level was selected to explore the distribution and predict early post-LT mortality. To determine the best cutoff values of LA, we used a classification and regression tree algorithm and maximally selected rank statistics with the smallest P value. Results The median intraoperative LA level was 4.4 mmol/L (range: 0.5-34.7, interquartile range: 3.0-6.2 mmol/L). Of the 3,338 patients, 1,884 (56.4%) had LA levels > 4.0 mmol/L and 188 (5.6%) had LA levels > 10 mmol/L. Patients with LA levels > 16.7 mmol/L and 13.5-16.7 mmol/L showed significantly higher 30-day mortality rates of 58.3% and 21.2%, respectively. For the prediction of the 90-day mortality, 8.4 mmol/L of intraoperative LA was the best cutoff value. Conclusions Approximately 6% of the LT recipients showed intraoperative hyperlactatemia of > 10 mmol/L during LT, and those with LA > 8.4 mmol/L were associated with significantly higher early post-LT mortality.
Collapse
Affiliation(s)
- Kyoung-Sun Kim
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sang-Ho Lee
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Bo-Hyun Sang
- Department of Anesthesiology and Pain Medicine, CHA Bundang Medical Center, CHA University School of Medicine, Seongnam, Korea
| | - Gyu-Sam Hwang
- Department of Anesthesiology and Pain Medicine, Laboratory for Cardiovascular Dynamics, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| |
Collapse
|
|
13
|
Zhang T, Guan YZ, Liu H. Association of Acidemia With Short-Term Mortality of Acute Myocardial Infarction: A Retrospective Study Base on MIMIC-III Database. Clin Appl Thromb Hemost 2021; 26:1076029620950837. [PMID: 32862673 PMCID: PMC7466881 DOI: 10.1177/1076029620950837] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Acute myocardial infarction (AMI) is a leading cause of death and not a few of these patients are combined with acidemia. This study aimed to detect the association of acidemia with short-term mortality of AMI patients. A total of 972 AMI patients were selected from the Medical Information Mart for Intensive Care (MIMIC) III database for analysis. Propensity-score matching (PSM) was used to reduce the imbalance. Kaplan-Meier survival analysis was used to compare the mortality, and Cox-proportional hazards model was used to detect related factors associated with mortality. After PSM, a total of 345 non-acidemia patients and 345 matched acidemia patients were included. The non-acidemia patients had a significantly lower 30-day mortality (20.0% vs. 28.7%) and lower 90-day mortality (24.9% vs. 31.9%) than the acidemia patients (P < 0.001 for all). The severe-acidemia patients (PH < 7.25) had the highest 30-day mortality (52.6%) and 90-day mortality (53.9%) than non-acidemia patients and mild-acidemia (7.25 ≤ PH < 7.35) patients (P < 0.001). In Cox-proportional hazards model, acidemia was associated with improved 30-day mortality (HR = 1.518; 95%CI = 1.110-2.076, P = 0.009) and 90-day mortality (HR = 1.378; 95%CI = 1.034 -1.837, P = 0.029). These results suggest that severe acidemia is associated with improved 30-day mortality and 90-day mortality of AMI patients.
Collapse
Affiliation(s)
- Tang Zhang
- Department of Cardiology, The Second Affiliated Hospital, 74626Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Yao-Zong Guan
- Department of Cardiology, Institute of Cardiovascular Diseases, The First Affiliated Hospital, 74626Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| | - Hao Liu
- Department of Cardiology, The Second Affiliated Hospital, 74626Guangxi Medical University, Nanning, Guangxi, People's Republic of China
| |
Collapse
|
|
14
|
Admission Serum Bicarbonate Predicts Adverse Clinical Outcomes in Hospitalized Cirrhotic Patients. Can J Gastroenterol Hepatol 2021; 2021:9915055. [PMID: 34055676 PMCID: PMC8149247 DOI: 10.1155/2021/9915055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2021] [Accepted: 05/05/2021] [Indexed: 01/11/2023] Open
Abstract
A low serum bicarbonate (SB) level is predictive of adverse outcomes in kidney injury, infection, and aging. Because the liver plays an important role in acid-base homeostasis and lactic acid metabolism, we speculated that such a relationship would exist for patients with cirrhosis. To assess the prognostic value of admission SB on adverse hospital outcomes, clinical characteristics were extracted and analyzed from a large electronic health record system. Patients were categorized based on admission SB (mEq/L) into 7 groups based on the reference range (22-25) into mildly (18-21), moderately (14-17), and severely (<14) decreased groups and mildly (26-29), moderately (30-33), and severely (>30) increased groups, and the relationship of SB category with the frequency of complications (acute kidney injury/hepatorenal syndrome, portosystemic encephalopathy, gastrointestinal bleeding, ascites, and spontaneous bacterial peritonitis) and hospital metrics (length of stay [LOS], admission to an intensive care unit [ICU], and mortality) was assessed. A total of 2,693 patients were analyzed. Mean SB was 22.9 ± 4.5 mEq/L. SB was within the normal range (22-25 mEq/L) in 1,072 (39.8%) patients, and 955 patients (36%) had a low SB. As the SB category decreased, the incidence of complications progressively increased (p < 0.001). Increased MELD-Na score and low serum albumin also correlated with frequency of complications (p < 0.001). As the SB category decreased, LOS, ICU admission, and mortality progressively increased (p < 0.001). On multivariate analysis, the association of decreased SB with higher odds of complications, LOS, ICU admission, and mortality persisted. Conclusion. Low admission SB in patients with cirrhosis is associated with cirrhotic complications, longer LOS, increased ICU admissions, and increased hospital mortality.
Collapse
|
|
15
|
[Alkalosis, albumin, ammonia and hepatic encephalopathy]. Med Klin Intensivmed Notfmed 2021; 116:358-359. [PMID: 33825943 DOI: 10.1007/s00063-021-00812-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
|
16
|
Gomez DE, Bedford S, Darby S, Palmisano M, MacKay RJ, Renaud DL. Acid-base disorders in sick goats and their association with mortality: A simplified strong ion difference approach. J Vet Intern Med 2020; 34:2776-2786. [PMID: 33140905 PMCID: PMC7694813 DOI: 10.1111/jvim.15956] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 10/23/2020] [Accepted: 10/23/2020] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVES To investigate the acid-base status of sick goats using the simplified strong ion difference (sSID) approach, to establish the quantitative contribution of sSID variables to changes in blood pH and HCO3 - and to determine whether clinical, acid-base, and biochemical variables on admission are associated with the mortality of sick goats. ANIMALS One hundred forty-three sick goats. METHODS Retrospective study. Calculated sSID variables included SID using 6 electrolytes unmeasured strong ions (USI) and the total nonvolatile buffer ion concentration in plasma (Atot ). The relationship between measured blood pH and HCO3 - , and the sSID variables was examined using forward stepwise linear regression. Cox proportional hazard models were constructed to assess associations between potential predictor variables and mortality of goats during hospitalization. RESULTS Hypocapnia, hypokalemia, hyperchloremia, hyperlactatemia, and hyperproteinemia were common abnormalities identified in sick goats. Respiratory alkalosis, strong ion acidosis, and Atot acidosis were acid-base disorders frequently encountered in sick goats. In sick goats, the sSID variables explained 97% and 100% of the changes in blood pH and HCO3 - , respectively. The results indicated that changes in the respiratory rate (<16 respirations per minute), USI, and pH at admission were associated with increased hazard of hospital mortality in sick goats. CONCLUSIONS AND CLINICAL IMPORTANCE The sSID approach is a useful methodology to quantify acid-base disorders in goats and to determine the mechanisms of their development. Clinicians should consider calculation of USI in sick goats as part of the battery of information required to establish prognosis.
Collapse
Affiliation(s)
- Diego E. Gomez
- Department of Large Animal Clinical SciencesCollege of Veterinary Medicine, University of FloridaGainesvilleFloridaUSA
- Department of Clinical StudiesOntario Veterinary College, University of GuelphGuelphOntarioCanada
| | - Sofia Bedford
- Department of Clinical StudiesOntario Veterinary College, University of GuelphGuelphOntarioCanada
| | - Shannon Darby
- Department of Large Animal Clinical SciencesCollege of Veterinary Medicine, University of FloridaGainesvilleFloridaUSA
| | - Megan Palmisano
- Department of Large Animal Clinical SciencesCollege of Veterinary Medicine, University of FloridaGainesvilleFloridaUSA
| | - Robert J. MacKay
- Department of Large Animal Clinical SciencesCollege of Veterinary Medicine, University of FloridaGainesvilleFloridaUSA
| | - David L. Renaud
- Department of Population MedicineOntario Veterinary College, University of GuelphGuelphOntarioCanada
| |
Collapse
|
|
17
|
Liu X, Feng Y, Zhu X, Shi Y, Lin M, Song X, Tu J, Yuan E. Serum anion gap at admission predicts all-cause mortality in critically ill patients with cerebral infarction: evidence from the MIMIC-III database. Biomarkers 2020; 25:725-732. [PMID: 33103496 DOI: 10.1080/1354750x.2020.1842497] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
BACKGROUND Recent studies reported that serum anion gap could be regarded as a prognostic biomarker for patients admitted to intensive care units. However, the association between AG and mortality in cerebral infarction patients remained largely unknown. METHODS Relevant clinical data were collected from Medical Information Mart for Intensive Care III. Patients were divided into three groups according to tertiles of AG. Kaplan-Meier curve and Cox proportional hazards models were used to evaluate the association between AG levels and all-cause mortality. Subgroup analyses were performed to verify the predictive role of AG on mortality. RESULTS Kaplan-Meier analysis showed that patients with higher AG had shorter survival time. Cox regression model indicated high AG as an independent risk factor of 30-day, 60-day and 180-day all-cause mortality (30-day: HR = 2.45, 95% CI = 1.21-4.97, 60-day: HR = 2.04, 95% CI = 1.07-3.89, and 180-day: HR = 1.85, 95% CI = 1.02-3.36). However, no significance was observed between AG and 365-day all-cause mortality (HR = 1.56, 95% CI = 0.87-2.78). CONCLUSIONS High AG was associated with increased risk of all-cause mortality, and AG could be an independent short-term prognostic factor for cerebral infarction.
Collapse
Affiliation(s)
- Xuefang Liu
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanlin Feng
- Program & Department of Clinical Laboratory Medicine, Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Xinyu Zhu
- Program & Department of Clinical Laboratory Medicine, Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Ying Shi
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Manting Lin
- Department of Pharmacy, Zhongnan Hospital of Wuhan University, Wuhan, Hubei, China
| | - Xiaoyan Song
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jiancheng Tu
- Program & Department of Clinical Laboratory Medicine, Center for Gene Diagnosis, Zhongnan Hospital of Wuhan University, Wuhan, China
| | - Enwu Yuan
- Department of Clinical Laboratory, The Third Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| |
Collapse
|
|
18
|
Lin X, Huang X, Wang L, Feng S, Chen X, Cai W, Huang Z. Prognostic Value of Acute-On-Chronic Liver Failure (ACLF) Score in Critically Ill Patients with Cirrhosis and ACLF. Med Sci Monit 2020; 26:e926574. [PMID: 32978936 PMCID: PMC7526342 DOI: 10.12659/msm.926574] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Background In the intensive care unit (ICU), critically ill patients with cirrhosis and acute-on-chronic liver failure (ACLF) continue to have high mortality rates. The AARC ACLF score is a simple, newly-developed score based on Asian ACLF patients, which performs well in prognosis. The present study attempted to verify the prognostic ability of AARC ACLF in non-Asian critically ill patients with cirrhosis and ACLF. Material/Methods We enrolled 786 patients. Relevant clinical data were collected within 24 h after admission to compare the differences between survivors and non-survivors, and all the patients were followed up for at least 180 days. Results The 28-day, 90-day, and 180-day mortality rates were 28.9% (227/786), 36.4% (286/786), and 40.3% (317/786), respectively. Multivariate Cox regression analysis showed that AARC ACLF score (HR: 1.375, 95% CI: 1.247–1.516, P<0.001) was an independent predictive factor of 28-day mortality, and the AUROC of the predictive ability in 28-day mortality of the AARC ACLF score was 0.754. In addition, the AARC ACLF score was regraded into 3 classes (low risk: AARC ACLF <9, intermediate risk: 9≤ AARC ACLF <12, and high risk: AARC ACLF ≥12). The AARC ACLF score can be used for dynamic assessment by retest at days 4–7. Conclusions The AARC ACLF score has a good predictive value for 28-day, 90-day, and 180-day mortality in non-Asian critically ill patients with cirrhosis and ACLF, which is not inferior to CLIF-C ACLFsLact and other models. It is easy to use at bedside, and it is dynamic and reliable.
Collapse
Affiliation(s)
- Xinran Lin
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Xielin Huang
- Department of Gastroenterology Surgery, The Second Affiliated Hospital of Wenzhou Medical University,, Wenzhou, Zhejiang, China (mainland)
| | - Li Wang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Shuyi Feng
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Xiaofu Chen
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Weimin Cai
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| | - Zhiming Huang
- Department of Gastroenterology and Hepatology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, Zhejiang, China (mainland)
| |
Collapse
|
|
19
|
Gao F, Lin MT, Yang XY, Cai MX, Nan H, Xie W, Huang ZM. Metabolic acidosis in critically ill patients with cirrhosis: Epidemiology and short-term mortality risk factors. TURKISH JOURNAL OF GASTROENTEROLOGY 2020; 30:883-891. [PMID: 31633484 DOI: 10.5152/tjg.2019.18813] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND/AIMS Metabolic acidosis is a common complication in patients with cirrhosis at the intensive care units (ICUs) and associated with increased mortality. The aim of our research was to explore the epidemiology and risk factors of metabolic acidosis in critically ill patients with cirrhosis. MATERIALS AND METHODS A total of 975 patients with cirrhosis were selected into our study, and all participants were followed up for at least 28 days. Cox regression model and machine-learning algorithm were used to identify the importance of different risk factors, respectively. Finally, an improved prognostic model as Model for End-stage Liver Disease and metabolic acidosis (MELD-MA) was developed. RESULTS Among the 975 patients with liver cirrhosis, 506 had metabolic acidosis, including 257 patients who had decompensated metabolic acidosis at ICU admission. The 28-day mortality was 41% (206/506) in patients with metabolic acidosis. Bilirubin (hazard ratio (HR): 1.023, 95% confidence interval (CI): 1.011-1.036), international normalized ratio (HR: 1.527, 95% CI: 1.332-1.750), pH (HR: 0.173, 95% CI: 0.047-0.640), BE-Lac (HR: 0.907, 95% CI: 0.868-0.948), and BE-Na (HR: 0.923, 95% CI: 0.859-0.991) were considered as independent prognostic parameters for 28-day mortality. MELD-NA had significantly higher discrimination (area under the receiver operating characteristic curve 0.79) than MELD and Child-Pugh score. CONCLUSION Critically ill patients with cirrhosis have a high mortality rate and poor prognosis because of the high prevalence of metabolic acidosis. Lactic acidosis is the worst prognosis of all types of metabolic acidosis. MELD-MA performs well on the short-term mortality assessment in critically ill patients with cirrhosis and metabolic acidosis.
Collapse
Affiliation(s)
- Feng Gao
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Miao-Tong Lin
- Department of Emergency Medicine, Intensive Care, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xing-Yi Yang
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Meng-Xing Cai
- Department of Cardiovascular Medicine, the Heart Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Hao Nan
- Department of Respiratory Medicine, the Third People's Hospital of Yueqing, Wenzhou, China
| | - Wei Xie
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Zhi-Ming Huang
- Department of Gastroenterology and Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| |
Collapse
|
|
20
|
Dhama K, Latheef SK, Dadar M, Samad HA, Munjal A, Khandia R, Karthik K, Tiwari R, Yatoo MI, Bhatt P, Chakraborty S, Singh KP, Iqbal HMN, Chaicumpa W, Joshi SK. Biomarkers in Stress Related Diseases/Disorders: Diagnostic, Prognostic, and Therapeutic Values. Front Mol Biosci 2019; 6:91. [PMID: 31750312 PMCID: PMC6843074 DOI: 10.3389/fmolb.2019.00091] [Citation(s) in RCA: 154] [Impact Index Per Article: 25.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2019] [Accepted: 09/11/2019] [Indexed: 02/05/2023] Open
Abstract
Various internal and external factors negatively affect the homeostatic equilibrium of organisms at the molecular to the whole-body level, inducing the so-called state of stress. Stress affects an organism's welfare status and induces energy-consuming mechanisms to combat the subsequent ill effects; thus, the individual may be immunocompromised, making them vulnerable to pathogens. The information presented here has been extensively reviewed, compiled, and analyzed from authenticated published resources available on Medline, PubMed, PubMed Central, Science Direct, and other scientific databases. Stress levels can be monitored by the quantitative and qualitative measurement of biomarkers. Potential markers of stress include thermal stress markers, such as heat shock proteins (HSPs), innate immune markers, such as Acute Phase Proteins (APPs), oxidative stress markers, and chemical secretions in the saliva and urine. In addition, stress biomarkers also play critical roles in the prognosis of stress-related diseases and disorders, and therapy guidance. Moreover, different components have been identified as potent mediators of cardiovascular, central nervous system, hepatic, and nephrological disorders, which can also be employed to evaluate these conditions precisely, but with stringent validation and specificity. Considerable scientific advances have been made in the detection, quantitation, and application of these biomarkers. The present review describes the current progress of identifying biomarkers, their prognostic, and therapeutic values.
Collapse
Affiliation(s)
- Kuldeep Dhama
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Shyma K. Latheef
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Maryam Dadar
- Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization, Karaj, Iran
| | - Hari Abdul Samad
- Division of Physiology and Climatology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Ashok Munjal
- Department of Genetics, Barkatullah University, Bhopal, India
| | - Rekha Khandia
- Department of Genetics, Barkatullah University, Bhopal, India
| | - Kumaragurubaran Karthik
- Central University Laboratory, Tamil Nadu Veterinary and Animal Sciences University, Chennai, India
| | - Ruchi Tiwari
- Department of Veterinary Microbiology and Immunology, College of Veterinary Sciences, UP Pandit Deen Dayal Upadhayay Pashu Chikitsa Vigyan Vishwavidyalay Evum Go-Anusandhan Sansthan, Mathura, India
| | - Mohd. Iqbal Yatoo
- Division of Veterinary Clinical Complex, Sher-E-Kashmir University of Agricultural Sciences and Technology of Kashmir, Srinagar, India
| | - Prakash Bhatt
- Teaching Veterinary Clinical Complex, College of Veterinary and Animal Sciences, Govind Ballabh Pant University of Agriculture and Technology, Pantnagar, India
| | - Sandip Chakraborty
- Department of Veterinary Microbiology, College of Veterinary Sciences and Animal Husbandry, Agartala, India
| | - Karam Pal Singh
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Hafiz M. N. Iqbal
- Tecnologico de Monterrey, School of Engineering and Sciences, Monterrey, Mexico
| | - Wanpen Chaicumpa
- Department of Parasitology, Faculty of Medicine, Center of Research Excellence on Therapeutic Proteins and Antibody Engineering, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sunil Kumar Joshi
- Division of Hematology, Oncology and Bone Marrow Transplantation, Department of Microbiology & Immunology, Department of Pediatrics, University of Miami School of Medicine, Miami, FL, United States
| |
Collapse
|
|
21
|
Dhama K, Latheef SK, Dadar M, Samad HA, Munjal A, Khandia R, Karthik K, Tiwari R, Yatoo MI, Bhatt P, Chakraborty S, Singh KP, Iqbal HMN, Chaicumpa W, Joshi SK. Biomarkers in Stress Related Diseases/Disorders: Diagnostic, Prognostic, and Therapeutic Values. Front Mol Biosci 2019. [PMID: 31750312 DOI: 10.3389/fmolb.2019.0009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Various internal and external factors negatively affect the homeostatic equilibrium of organisms at the molecular to the whole-body level, inducing the so-called state of stress. Stress affects an organism's welfare status and induces energy-consuming mechanisms to combat the subsequent ill effects; thus, the individual may be immunocompromised, making them vulnerable to pathogens. The information presented here has been extensively reviewed, compiled, and analyzed from authenticated published resources available on Medline, PubMed, PubMed Central, Science Direct, and other scientific databases. Stress levels can be monitored by the quantitative and qualitative measurement of biomarkers. Potential markers of stress include thermal stress markers, such as heat shock proteins (HSPs), innate immune markers, such as Acute Phase Proteins (APPs), oxidative stress markers, and chemical secretions in the saliva and urine. In addition, stress biomarkers also play critical roles in the prognosis of stress-related diseases and disorders, and therapy guidance. Moreover, different components have been identified as potent mediators of cardiovascular, central nervous system, hepatic, and nephrological disorders, which can also be employed to evaluate these conditions precisely, but with stringent validation and specificity. Considerable scientific advances have been made in the detection, quantitation, and application of these biomarkers. The present review describes the current progress of identifying biomarkers, their prognostic, and therapeutic values.
Collapse
Affiliation(s)
- Kuldeep Dhama
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Shyma K Latheef
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Maryam Dadar
- Razi Vaccine and Serum Research Institute, Agricultural Research, Education and Extension Organization, Karaj, Iran
| | - Hari Abdul Samad
- Division of Physiology and Climatology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Ashok Munjal
- Department of Genetics, Barkatullah University, Bhopal, India
| | - Rekha Khandia
- Department of Genetics, Barkatullah University, Bhopal, India
| | - Kumaragurubaran Karthik
- Central University Laboratory, Tamil Nadu Veterinary and Animal Sciences University, Chennai, India
| | - Ruchi Tiwari
- Department of Veterinary Microbiology and Immunology, College of Veterinary Sciences, UP Pandit Deen Dayal Upadhayay Pashu Chikitsa Vigyan Vishwavidyalay Evum Go-Anusandhan Sansthan, Mathura, India
| | - Mohd Iqbal Yatoo
- Division of Veterinary Clinical Complex, Sher-E-Kashmir University of Agricultural Sciences and Technology of Kashmir, Srinagar, India
| | - Prakash Bhatt
- Teaching Veterinary Clinical Complex, College of Veterinary and Animal Sciences, Govind Ballabh Pant University of Agriculture and Technology, Pantnagar, India
| | - Sandip Chakraborty
- Department of Veterinary Microbiology, College of Veterinary Sciences and Animal Husbandry, Agartala, India
| | - Karam Pal Singh
- Division of Pathology, ICAR-Indian Veterinary Research Institute, Bareilly, India
| | - Hafiz M N Iqbal
- Tecnologico de Monterrey, School of Engineering and Sciences, Monterrey, Mexico
| | - Wanpen Chaicumpa
- Department of Parasitology, Faculty of Medicine, Center of Research Excellence on Therapeutic Proteins and Antibody Engineering, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Sunil Kumar Joshi
- Division of Hematology, Oncology and Bone Marrow Transplantation, Department of Microbiology & Immunology, Department of Pediatrics, University of Miami School of Medicine, Miami, FL, United States
| |
Collapse
|
|
22
|
Perez Ruiz de Garibay A, Kellum JA, Honigschnabel J, Kreymann B. Respiratory and metabolic acidosis correction with the ADVanced Organ Support system. Intensive Care Med Exp 2019; 7:56. [PMID: 31535309 PMCID: PMC6751235 DOI: 10.1186/s40635-019-0269-7] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2019] [Accepted: 09/09/2019] [Indexed: 01/23/2023] Open
Abstract
Background The lung, the kidney, and the liver are major regulators of acid-base balance. Acidosis due to the dysfunction of one or more organs can increase mortality, especially in critically ill patients. Supporting compensation by increasing ventilation or infusing bicarbonate is often ineffective. Therefore, direct removal of acid may represent a novel therapeutic approach. This can be achieved with the ADVanced Organ Support (ADVOS) system, an enhanced renal support therapy based on albumin dialysis. Here, we demonstrate proof of concept for this technology. Methods An ex vivo model of either hypercapnic (i.e., continuous CO2 supply) or lactic acidosis (i.e., lactic acid infusion) using porcine blood was subjected to hemodialysis with ADVOS. A variety of operational parameters including blood and dialysate flows, different dialysate pH settings, and acid and base concentrate compositions were tested. Comparisons with standard continuous veno-venous hemofiltration (CVVH) using high bicarbonate substitution fluid and continuous veno-venous hemodialysis (CVVHD) were also performed. Results Sixty-one milliliters per minute (2.7 mmol/min) of CO2 was removed using a blood flow of 400 ml/min and a dialysate pH of 10 without altering blood pCO2 and HCO3− (36 mmHg and 20 mmol/l, respectively). Up to 142 ml/min (6.3 mmol/min) of CO2 was eliminated if elevated pCO2 (117 mmHg) and HCO3− (63 mmol/l) were allowed. During continuous lactic acid infusion, an acid load of up to 3 mmol/min was compensated. When acidosis was triggered, ADVOS multi normalized pH and bicarbonate levels within 1 h, while neither CVVH nor CVVHD could. The major determinants to correct blood pH were blood flow, dialysate composition, and initial acid-base status. Conclusions In conclusion, ADVOS was able to remove more than 50% of the amount of CO2 typically produced by an adult human. Blood pH was maintained stable within the physiological range through compensation of a metabolic acid load by albumin dialysate. These in vitro results will require confirmation in patients.
Collapse
Affiliation(s)
| | - John A Kellum
- Center for Critical Care Nephrology, Department of Critical Care Medicine, University of Pittsburgh Medical Center, Pittsburgh, USA
| | | | | |
Collapse
|
|
23
|
Sun DQ, Zhang L, Zheng CF, Liu WY, Zheng KI, Chen XM, Zheng MH, Yuan WJ. Metabolic Acidosis in Critically Ill Cirrhotic Patients with Acute Kidney Injury. J Clin Transl Hepatol 2019; 7:112-121. [PMID: 31293910 PMCID: PMC6609841 DOI: 10.14218/jcth.2019.00013] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2019] [Revised: 04/20/2019] [Accepted: 04/22/2019] [Indexed: 12/12/2022] Open
Abstract
Background and Aims: The metabolic acid-base disorders have a high incidence of acute kidney injury (AKI) in critically ill cirrhotic patients (CICPs). The aims of our study were to ascertain the composition of metabolic acidosis of CICPs with AKI and explore its relationship with hospital mortality. Methods: Three-hundred and eighty consecutive CICPs with AKI were eligible for the cohort study. Demographic, clinical and laboratory parameters were recorded and arterial acid-base state was analyzed by the Stewart and Gilfix methodology. Results: Net metabolic acidosis, lactic acidosis, acidosis owing to unmeasured anions, acidemia, and dilutional acidosis were less frequent in the non-survival group compared to the survival group of CICPs. The presence of acidemia, acidosis owing to unmeasured anions, and lactic acidosis were independently associated with increased risk of intensive care unit 30-day mortality, with hazard ratios of 2.11 (95% confidence interval (CI): 1.43-3.12), 3.38 (95% CI: 2.36-4.84), and 2.16 (95% CI: 1.47-3.35), respectively. After full adjustment for confounders, the relationship between acidosis owing to unmeasured anions with hospital mortality was still significant, with hazard ratio of 2.29 (95% CI: 1.22-4.30). Furthermore, arterial lactate concentration in combination with chronic liver failure-sequential organ failure assessment and BEUMA had the strongest ability to differentiate 30-day mortality (area under the receiver operating characteristic curve: 0.79, 95% CI: 0.74-0.83). Conclusions: CICPs with AKI exhibit a complex metabolic acidosis during intensive care unit admission. Lactic acidosis and BEUMA, novel markers of acid-base disorders, show promise in predicting mortality rate of CICPs with AKI.
Collapse
Affiliation(s)
- Dan-Qin Sun
- Department of Nephrology, The Affiliated Wuxi No. 2 People’s Hospital of Nanjing Medical University, Wuxi, China
- Department of Nephrology, Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| | - Lai Zhang
- Department of Nephrology, The Affiliated Wuxi No. 2 People’s Hospital of Nanjing Medical University, Wuxi, China
| | - Chen-Fei Zheng
- Department of Nephrology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wen-Yue Liu
- Department of Endocrinology, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Kenneth I. Zheng
- NAFLD Research Center, Department of Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Xiao-Ming Chen
- Zhejiang Engineering Research Center of Intelligent Medicine, The First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Ming-Hua Zheng
- NAFLD Research Center, Department of Hepatology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou, China
| | - Wei-Jie Yuan
- Department of Nephrology, Shanghai General Hospital of Nanjing Medical University, Shanghai, China
| |
Collapse
|
|
24
|
Roedl K, Spiel AO, Nürnberger A, Horvatits T, Drolz A, Hubner P, Warenits AM, Sterz F, Herkner H, Fuhrmann V. Hypoxic liver injury after in- and out-of-hospital cardiac arrest: Risk factors and neurological outcome. Resuscitation 2019; 137:175-182. [PMID: 30831218 DOI: 10.1016/j.resuscitation.2019.02.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/10/2018] [Revised: 02/24/2019] [Accepted: 02/24/2019] [Indexed: 01/19/2023]
Abstract
BACKGROUND Hypoxic liver injury (HLI) is a frequent and life-threatening complication in critically ill patients that occurs in up to ten percent of critically ill patients. However, there is a lack of data on HLI following cardiac arrest and its clinical implications on outcome. Aim of this study was to investigate incidence, outcome and functional outcome of patients with HLI after in-hospital cardiac arrest (IHCA) and out-of-hospital cardiac arrest (OHCA). METHODS We conducted an analysis of a cardiac arrest registry data over a 7-year period. All patients with non-traumatic OHCA and IHCA with return of spontaneous circulation (ROSC) treated at the emergency department of a tertiary care hospital were included in the study. HLI was defined according to established criteria. Predictors of HLI, occurrence, clinical and neurological outcome were assessed using multivariable regression. RESULTS Out of 1068 patients after IHCA and OHCA with ROSC, 219 (21%) patients developed HLI. Rate of HLI did not differ significantly in IHCA and OHCA patients. Multivariate regression analysis identified time-to-ROSC [OR 1.18, 95% CI (1.01-1.38); p < 0.05], presence of cardiac failure [OR 2.57, 95% CI (1.65-4.01); p < 0.001] and Charlson comorbidity index [OR 0.83, 95% CI (0.72-0.95); p < 0.01] as independent predictors for occurrence of HLI. Good functional outcome was significantly lower in patients suffering from HLI after 28-days (35% vs. 48%, p < 0.001) and 1-year (34% vs. 44%, p < 0.001). Occurrence of HLI was associated with unfavourable neurological outcome [OR 1.74, 95% CI (1.16-2.61); p < 0.01] in multivariate regression analysis. CONCLUSION New onset of HLI is a frequent finding after IHCA and OHCA. HLI is associated with increased mortality, unfavourable neurological and overall outcome.
Collapse
Affiliation(s)
- Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| | - Alexander O Spiel
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Alexander Nürnberger
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Thomas Horvatits
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| | - Andreas Drolz
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| | - Pia Hubner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | | | - Fritz Sterz
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Harald Herkner
- Department of Emergency Medicine, Medical University of Vienna, Vienna, Austria.
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Department of Internal Medicine 3, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|