Increased mortality in critically ill patients with mild or moderate hyperbilirubinemia

Hepatic function markers as prognostic factors in patients with acute kidney injury undergoing continuous renal replacement therapy

Acute kidney injury (AKI) requiring continuous renal replacement therapy (CRRT), secondary to cardiovascular disease and sepsis, is associated with high in-hospital mortality. Although studies have examined cardiovascular disease and sepsis in AKI, the association between AKI and hepatic functional impairment remains unclear. We hypothesized that hepatic function markers would predict mortality in patients undergoing CRRT. We included 1,899 CRRT patients from a multi-centre database. In Phase 1, participants were classified according to the total bilirubin (T-Bil) levels on the day of, and 3 days after, CRRT initiation: T-Bil < 1.2, 1.2 ≤ T-Bil < 2, and T-Bil ≥ 2 mg/dL. In Phase 2, propensity score matching (PSM) was performed to examine the effect of a T-Bil cutoff of 1.2 mg/dL (supported by the Sequential Organ Failure Assessment score); creating two groups based on a T-Bil cutoff of 1.2 mg/dL 3 days after CRRT initiation. The primary endpoint was total mortality 90 days after CRRT initiation, which was 34.7% (n = 571). In Phase 1, the T-Bil, aspartate transaminase (AST), alanine transaminase (ALT), and AST/ALT (De Ritis ratio) levels at CRRT initiation were not associated with the prognosis, while T-Bil, AST, and the De Ritis ratio 3 days after CRRT initiation were independent factors. In Phase 2, T-Bil ≥1.2 mg/dL on day 3 was a significant independent prognostic factor, even after PSM [hazard ratio: 2.41 (95% CI; 1.84-3.17), p < 0.001]. T-Bil ≥1.2 mg/dL 3 days after CRRT initiation predicted 90-day mortality. Changes in hepatic function markers in acute renal failure may enable stratification of high-risk patients.

Correlation of bilirubin and toxic bile acids in critically ill patients with cholestatic liver dysfunction and adsorber application

Bilirubin is one of the most frequently used laboratory values to monitor critically ill patients with cholestatic liver dysfunction. Besides bilirubin, toxic bile acids (TBAs), which may cause severe organ damage, are typically elevated. A correlation between both parameters seems plausible, but data are lacking. The aim was to investigate whether there is a correlation between bilirubin and TBAs in patients' blood and whether a compareable reduction can be observed during the use of the adsorber CytoSorb (CS). As part of the Cyto-SOLVE study (NCT04913298), 16 critically ill patients with cholestatic liver dysfunction, bilirubin concentration > 10 mg/dl, continuous kidney replacement therapy and CS-application were investigated. Bilirubin and TBA concentrations were measured from arterial blood at defined time points (before start, after 6 and 12 h). Relative reduction (RR) was calculated using the formula[Formula: see text]. A moderate to high correlation between bilirubin and TBA concentration at all defined timepoints (rstart=0.64, p = 0.008; r6h = 0.85, p < 0.001, r12h = 0.72, p = 0.002) was observed. In the first six hours of CS-application, a significant elimination of TBA (median TBA: 30.8→20.1µmol/l, p < 0.001) and bilirubin (median bilirubin: 17.1→11.9 mg/dl, p < 0.001) was observed. The median RR after 6 h was 26.1% and 39.8% for bilirubin and TBA, respectively. No further reduction was observed after 12 h (RRbilirubin: - 0.6%, RRTBA: 1.8%). There was an at least moderate correlation between bilirubin and TBA in patients with cholestatic liver dysfunction. Therefore, bilirubin seems to be a suitable surrogate parameter for TBA elimination during CytoSorb application.

Correlation between Bilirubin Elimination with the Cytokine Adsorber CytoSorb® and Mortality in Critically Ill Patients with Hyperbilirubinemia

INTRODUCTION

Hyperbilirubinemia is often the first evidence for any kind of liver disorder and over one-third of all patients in intensive care units (ICU) show elevated bilirubin concentrations. In critically ill patients, high concentrations of serum bilirubin are correlated with a poor outcome. Therapies to lower bilirubin concentrations are often just symptomatically and their effect on the patients' outcome is hardly evaluated. Therefore, this study investigates whether the extracorporeal elimination of bilirubin with the cytokine adsorber CytoSorb® (CS) reduces mortality in patients with hyperbilirubinemia.

METHODS

Patients with bilirubin concentrations >10 mg/dL at the ICU were screened for evaluation from 2018 to 2020. Patients with kidney replacement therapy and older than 18 years were included. Patients with continuously decreasing bilirubin concentrations after liver transplantation or other liver support systems (i.e., Molecular Adsorbents Recirculating System [MARS®], Advanced Organ Support [ADVOS]) were excluded. CS therapy was used in clinical routine and was indicated by the treating physicians. Statistical analysis was performed with IBM SPSS statistics utilizing a multivariate model. Primary outcome measure was the effect of CS on the 30-day mortality.

RESULTS

Data from 82 patients (mean Simplified Acute Physiology Score [SAPS] II: 74 points, mean bilirubin: 18 mg/dL, mean lactate: 3.7 mmol/L) were analyzed. There were no significant differences in patients with and without CS treatment. The multivariate model showed no significant effect of CS therapy (p = 0.402) on the 30-day mortality. In addition, a significant effect of bilirubin concentration (p = 0.274) or Model for End-Stage Liver Disease score (p = 0.928) on the 30-day mortality could not be shown. In contrast, lactate concentration (p = 0.001, b = 0.044) and SAPS II (p = 0.025, b = 0.008) had significant impact on 30-day mortality.

CONCLUSION

The use of CS in patients with hyperbilirubinemia did not result in a significant reduction in 30-day mortality. Randomized and controlled studies with mortality as primary outcome measure are needed in the future to justify their use.

Epidemiology, drug resistance analysis and mortality risk factor prediction of gram-negative bacteria infections in patients with allogeneic hematopoietic stem cell transplantation

Allogeneic hematopoietic stem cell transplantation (allo-HSCT) is an effective treatment for many malignant and refractory diseases. However, infections, as the most common complication after transplantation, often lead to poor long-term prognosis of patients. In this study, we collected electronic medical records of allo-HSCT recipients with gram-negative bacteria (GNB) infections between January 2012 and September 2021, analyzed epidemiological characteristics and antibiotic sensitivity, and determined independent risk factors for carbapenem-resistant GNB (CR-GNB) infections and death by Logistic and Cox regression models. During the 9-year period, 183 of 968 patients developed GNB infections, of which 58 died. The most common pathogen was Klebsiella pneumoniae. CR-GNB, especially carbapenem-resistant Klebsiella pneumonia (CRKP), carbapenem-resistant Acinetobacter baumannii (CRAB) and carbapenem-resistant Escherichia coli (CREC) had a high resistance rate to commonly used clinical antibiotics. Independent risk factors for CR-GNB infections were use of carbapenem antibiotics for >3 days one month before transplantation (OR = 3.244, 95% CI 1.428-7.369, P = 0.005), use of special immunosuppressants after transplantation (OR = 1.21, 95% CI 1.008-1.452, P = 0.041), and time of hematopoietic reconstruction >20 days (OR = 2.628, 95% CI 1.369-5.043, P = 0.004). Independent risk factors for mortality were interval between diagnosis and transplantation >180 days (HR = 2.039, 95% CI 1.05 to 3.963, P = 0.035), total bilirubin levels during infection >34.2 μmol/L (HR = 3.39, 95% CI 1.583-7.256, P = 0.002) and septic shock (HR = 5.345, 95% CI 2.655-10.761, P = 0.000). In conclusion, GNB has a high incidence and mortality in allo-HSCT recipients. Early transplantation for eligible patients, attention to liver function protection, timely identification and treatment of septic shock can help to improve the prognosis of patients.

Critical care hepatology: definitions, incidence, prognosis and role of liver failure in critically ill patients

Organ dysfunction or overt failure is a commonplace event in the critically ill affecting up to 70% of patients during their stay in the ICU. The outcome depends on the resolution of impaired organ function, while a domino-like deterioration of organs other than the primarily affected ones paves the way for increased mortality. “Acute Liver Failure” was defined in the 1970s as a rare and potentially reversible severe liver injury in the absence of prior liver disease with hepatic encephalopathy occurring within 8 weeks. Dysfunction of the liver in general reflects a critical event in “Multiple Organ Dysfunction Syndrome” due to immunologic, regulatory and metabolic functions of liver parenchymal and non-parenchymal cells. Dysregulation of the inflammatory response, persistent microcirculatory (hypoxic) impairment or drug-induced liver injury are leading problems that result in “secondary liver failure,” i.e., acquired liver injury without underlying liver disease or deterioration of preexisting (chronic) liver disease (“Acute-on-Chronic Liver Failure”). Conventional laboratory markers, such as transaminases or bilirubin, are limited to provide insight into the complex facets of metabolic and immunologic liver dysfunction. Furthermore, inhomogeneous definitions of these entities lead to widely ranging estimates of incidence. In the present work, we review the different definitions to improve the understanding of liver dysfunction as a perpetrator (and therapeutic target) of multiple organ dysfunction syndrome in critical care.

Graphic Abstract

Immunomodulation by Hemoadsorption—Changes in Hepatic Biotransformation Capacity in Sepsis and Septic Shock: A Prospective Study

Background: Sepsis is often associated with liver dysfunction, which is an indicator of poor outcomes. Specific diagnostic tools that detect hepatic dysfunction in its early stages are scarce. So far, the immune modulatory effects of hemoadsorption with CytoSorb^® on liver function are unclear. Method: We assessed the hepatic function by using the dynamic LiMAx^® test and biochemical parameters in 21 patients with sepsis or septic shock receiving CytoSorb^® in a prospective, observational study. Points of measurement: T₁: diagnosis of sepsis or septic shock; T₂ and T₃: 24 h and 48 h after the start of CytoSorb^®; T₄: 24 h after termination of CytoSorb^®. Results: The hepatic biotransformation capacity measured by LiMAx^® was severely impaired in up to 95 % of patients. Despite a rapid shock reversal under CytoSorb^®, a significant improvement in LiMAx^® values appeared from T₃ to T₄. This decline and recovery of liver function were not reflected by common parameters of hepatic metabolism that remained mostly within the normal range. Conclusions: Hepatic dysfunction can effectively and safely be diagnosed with LiMAx^® in ventilated ICU patients under CytoSorb^®. Various static liver parameters are of limited use since they do not adequately reflect hepatic dysfunction and impaired hepatic metabolism.

Evaluation of qSOFA score, and conjugated bilirubin and creatinine levels for predicting 28‑day mortality in patients with sepsis

Sepsis is a dangerous disease that develops rapidly and has a high mortality rate. A timely and accurate assessment of the patient's condition is beneficial in improving prognosis and reducing mortality. Therefore, the present study was designed to investigate the potential association between quick sequential organ failure assessment (qSOFA) scores and biochemical indicators, such as conjugated bilirubin (CB) and creatinine levels, with the 28-day prognosis of patients with sepsis in a retrospective observational study. All cases were divided into survival and non-survival groups on the 28th day after diagnosis. The qSOFA scores, and CB and creatinine levels were significantly higher in the non-survival group than in the survival group (both P<0.01). Cox regression models identified CB [hazard ratio (HR), 1.006; P=0.002] and creatinine levels (HR, 1.002; P=0.024) as independent factors affecting 28-day mortality. The area under the curve (AUC) for CB and creatinine levels plus qSOFA score was 0.792 (95% confidence interval, 0.745-0.834), which was larger than the values for CB level, creatinine level and qSOFA score alone (all P<0.01) in the prognosis of 28-day mortality. The cut-off value of CB and creatinine levels plus qSOFA score for the 28-day mortality was 0.275 (-2.466 + 0.012 x CB + 0.002 x creatinine + 1.289 x qSOFA). Patients with lower combined predictor values had a better prognosis as demonstrated by Kaplan-Meier survival curves (log-rank test, 10.060; P=0.002). In both the septic shock and sepsis groups, the combined predictor value was higher in the non-survival group than in the survival group (P<0.001). Therefore, an increase in the combined predictor value of CB and creatinine levels plus qSOFA score may be an important predictor of disease progression and prognosis in patients with sepsis and septic shock.

Incidence, Clinical Characteristics and Outcomes of Early Hyperbilirubinemia in Critically Ill Patients: Insights From the MARS Study

OBJECTIVE

To investigate the incidence, clinical characteristics and outcomes of early hyperbilirubinemia in critically ill patients.

DESIGN AND SETTING

This is a post hoc analysis of a prospective multicenter cohort study.

PATIENTS

Patients with measured bilirubin levels within the first 2 days after ICU admission were eligible. Patients with liver cirrhosis were excluded.

ENDPOINTS

The primary endpoint was the incidence of early hyperbilirubinemia, defined as bilirubin ≥33 μmol/L within 2 days after ICU admission. Secondary endpoints included clinical characteristics of patients with versus patients without early hyperbilirubinemia, and outcomes up to day 30.

RESULTS

Of 4,836 patients, 559 (11.6%) patients had early hyperbilirubinemia. Compared to patients without early hyperbilirubinemia, patients with early hyperbilirubinemia presented with higher severity of illness scores, and higher incidences of sepsis and organ failure. After adjustment for confounding variables, early hyperbilirubinemia remained associated with mortality at day 30 (odds ratio, 1.31 [95%-confidence interval 1.06-1.60]; P = 0.018). Patients with early hyperbilirubinemia and thrombocytopenia (interaction P-value = 0.005) had a higher likelihood of death within 30 days (odds ratio, 2.61 [95%-confidence interval 2.08-3.27]; P < 0.001) than patients with early hyperbilirubinemia and a normal platelet count (odds ratio, 1.09 [95%-confidence interval 0.75-1.55]; P = 0.655).

CONCLUSIONS

Early hyperbilirubinemia occurs frequently in the critically ill, and these patients present with higher disease severity and more often with sepsis and organ failures. Early hyperbilirubinemia has an association with mortality, albeit this association was only found in patients with concomitant thrombocytopenia.

Long-term mortality predictors of ICU fungaemia

Bloodstream fungal infections have a high mortality rate. There is little data about the long-term mortality rate of fungaemia.This study aimed to explore the mortality of fungaemia and the influencing factors associated with death. In total, 204 intensive care unit (ICU) patients with fungaemia from Multi-parameter Intelligent Monitoring in Intensive Care-III (MIMIC-III) Database were studied. Age, gender, major underlying diseases, data about vital signs and blood test results were analysed to identify the predictors of the mortality and prognosis of fungaemia in ICU patients. Cox regression models were constructed, together with Kaplan−Meier survival curves. The 30-day, 1-year, 2-year, 3-year and 4-year mortality rates were 41.2%, 62.3%, 68.1%, 72.5% and 75%, respectively. Age (P ＜ 0.001, OR = 1.530; P ＜ 0.001, OR = 1.485)，serum bilirubin (P = 0.016, OR = 2.125；P = 0.001, OR = 1.748) and international normalised ratio (INR) (P = 0.001, OR = 2.642; P ＜ 0.001 OR = 2.065) were predictors of both the 30-day and 4-year mortality rates. Renal failure (P = 0.009, OR = 1.643) performed good in prediction of the 4-year mortality. The mortality of fungaemia is high. Age，the serum bilirubin and INR are good predictors of the 30-day and 4-year mortality rates of fungaemia. Renal failure has good performance in predicting the long-term mortality.

Risk factors and mortality associated with multidrug-resistant gram-negative bacterial infection in adult patients with abdominal surgery

BACKGROUND

Multidrug-resistant (MDR) gram-negative bacterial (GNB) infections remain a significant cause of morbidity and mortality among surgical patients. The objective of our study was to recognize the risk factors for MDR GNB infection in patients with abdominal surgery and determine the predictors independently associated with death.

METHODS

From 2010 to 2017, a retrospective cohort study was conducted among patients with abdominal surgery admitted in surgical intensive care unit (ICU). Patients with GNB infections were included for analyses.

RESULTS

A total of 364 patients with abdominal surgery experienced GNB infections, among them, 117 (32.1%) were MDR GNB infection. Of 133 MDR GNB isolates, the most frequent isolate was Escherichia coli (45.1%). Patients with MDR GNB infection had significantly longer ventilator days and hospital stay, as well as higher 30-day and in-hospital mortality compared to non-MDR GNB patients. Multivariable analysis showed longer length of pre-ICU stay, surgical re-exploration, receipt of group 2 carbapenems (e.g. imipenem, meropenem and doripenem) and fluoroquinolones, and higher total bilirubin were independent risk factors for the acquisition of MDR GNB infection. Predictors for 30-day mortality among patients with MDR GNB infection were chronic kidney disease, receipt of group 2 carbapenems and inappropriate empirical antimicrobial therapy.

CONCLUSIONS

This study provides important information about the risk factors for subsequent MDR GNB infection and 30-day mortality among the patients with abdominal surgery.

The role of bilirubin to albumin ratio as a predictor for mortality in critically ill patients without existing liver or biliary tract disease

Background:

Hyperbilirubinemia and hypoalbuminemia are frequently appeared and associated with poor prognosis in critically ill patients. We aim to evaluate the association between the bilirubin to albumin ratio and prognosis in intensive care unit (ICU) patients.

Methods:

This was a retrospective study of 731 patients who were admitted to the medical intensive care unit (MICU) at a tertiary-care center from July 2015 to September 2017. We analyzed the bilirubin to albumin ratio on admission to the MICU, including clinical characteristics and other examinations.

Results:

The overall 28-day survival of MICU patients was 69.1%. On univariate analysis, Acute Physiology and Chronic Health Evaluation (APACHE) II score (P<0.001), Sequential Organ Failure Assessment score (P<0.001), Simplified Acute Physiology Score II score (P<0.001), Creactive protein (P=0.015), and bilirubin/albumin ratio (P<0.001) were associated with mortality of ICU patients. The receiver operating characteristic curves for ICU patients mortality between bilirubin to albumin ratio and APACHE II score were not statistically significant (P=0.282). On multivariate analysis, higher APACHE II score (hazard ratio [HR], 1.05; 95% CI, 1.03 to 1.06; P<0.001) and bilirubin to albumin ratio (HR, 1.65; 95% CI, 1.23 to 2.20; P=0.001) were independently related to the ICU patient mortality.

Conclusions:

A higher bilirubin to albumin ratio was related to the unfavorable prognosis and mortality in critically ill patients.

Hemoadsorption in isolated conjugated hyperbilirubinemia after extracorporeal membrane oxygenation support. Cholestasis of sepsis: A case report and review of the literature on differential causes of jaundice in ICU patient

Hyperbilirubinemia occurs in up to 40% of critically ill. In ICU, hyperbilirubinemia is an independent factor that influences patients’ morbidity and mortality. Jaundice can reflect the course of disease or be caused by treatment (e.g. extracorporeal membrane oxygenation (ECMO)), thus can be difficult to differentiate. Sepsis was also associated with development of jaundice secondary to intrahepatic cholestasis. Prolonged cholestasis should be addressed to avoid liver damage. The patient with diagnosis of septic shock and severe acute respiratory distress syndrome was retrieved to our hospital for ECMO. Three days after initiation of ECMO, the patient developed jaundice, with increase of bilirubin, Gamma-glutamyltransferase and Alkaline phosphatase, without elevation of alanine aminotransferase and INR. Although ECMO was stopped, bilirubin serum levels were increasing, reaching the peak of 18.41 mg/dL of total and 15.67 mg/dL of direct bilirubin. Abdominal computed tomography showed homogeneous liver and non-dilated bile ducts. Viral hepatitis was excluded. CIOMS/RUCAM score was 0. Sepsis-related cholestasis was diagnosed. Despite cessation of sedation, the patient remained unconscious. Hemoadsorption therapy was initiated due to prolonged high levels of conjugated bilirubin. After 48 h of CytoSorb treatment, total bilirubin level was decreased to 2.4 mg/dL, the patient regained spontaneous eyes opening and could be transferred to regional hospital. Hyperbilirubinemia did not return in 3 months. Sepsis-related cholestasis is a diagnosis of exclusion that should be considered in case of jaundice in critically ill patients. In our patient, CytoSorb was a useful therapeutic option in prolonged cholestasis. Adsorption therapy was able to facilitate long-term regain of balance between inflammatory process, cytokine production and bilirubin turnover in the liver.

Delayed Antibiotic Therapy and Organ Dysfunction in Critically Ill Septic Patients in the Emergency Department

Background: We investigated the effect of antibiotic timing on outcomes based on changes in surrogate markers of organ failure, including platelet, serum bilirubin, serum creatinine levels, and the PaO₂/FiO₂ (P/F) ratio. Methods: This was a single-center, retrospective observational study of critically ill septic patients who presented to the emergency department (ED). The study period extended from August 2008 to September 2016. The primary outcomes included changes in platelet, serum bilirubin, serum creatinine levels, and the P/F ratio (δ-platelet, δ-serum bilirubin, δ-serum creatinine, and δ-P/F ratio were calculated as values measured on Day 3; values measured at ED enrollment). A multivariable linear regression model was developed to assess variables related to outcomes (δ-platelet, δ-serum bilirubin, δ-serum creatinine, and δ-P/F ratio). Results: We analyzed 1784 patients who met the inclusion criteria. The overall 28-day mortality was 14% (n = 256/1784). On multivariable linear regression analysis, the hourly delay in antibiotic therapy was significantly associated with a decrease in δ-platelet count (coefficient, −1.741; standard error, 0.740; p = 0.019), and an increase in δ-serum bilirubin (coefficient, 0.054; standard error, 0.021; p = 0.009). In contrast, it was not associated with δ-creatinine (coefficient, 0.008; standard error, 0.010; p = 0.434) or the δ-P/F ratio (coefficient, −0.797; standard error, 1.858; p = 0.668). Conclusion: The hourly delay of antibiotic therapy was associated with decreased platelet count and increased serum bilirubin concentration in critically ill septic patients during the first three days of ED admission.

Helpful Only When Elevated: Initial Serum Lactate in Stable Emergency Department Patients with Sepsis Is Specific, but Not Sensitive for Future Deterioration

BACKGROUND

Early emergency department (ED) identification of septic patients at risk of deterioration is critical. Lactate is associated with 28-day mortality in admitted patients, but little evidence exists on its use in predicting short-term deterioration.

OBJECTIVE

Our aim was to determine the role of initial serum lactate for prediction of short-term deterioration in stable ED patients with suspected sepsis.

METHODS

We conducted a prospective cohort study of adult ED sepsis patients. Venous lactate was obtained within 2 h of ED arrival. Main outcome was subsequent deterioration (defined as any of the following: death, intensive care admission > 24 h, intubation, vasoactive medications for > 1 h, or noninvasive positive pressure ventilation for > 1 h) within 72 h. Patients meeting any endpoint within 1 h of arrival were excluded.

RESULTS

Nine hundred and eighty-five patients were enrolled, of whom 84 (8.5%) met the primary outcome of deterioration. Initial lactate ≥ 4.0 mmol/L had a specificity of 97% (95% confidence interval [CI] 94-100%), but a sensitivity of 27% (95% CI 18-37%) for predicting deterioration, with positive and negative likelihood ratios of 10.7 (95% CI 6.3-18.3) and 0.8 (95% CI 0.7-0.9), respectively. A lower threshold of lactate (≥2.0 mmol/L) had a sensitivity of 67% (95% CI 55-76%) and specificity of 66% (95% CI 63-69%), with corresponding positive and negative likelihood ratios of 2.0 (95% CI 1.7-2.3) and 0.5 (95% CI 0.4-0.7).

CONCLUSIONS

High ED lactate is predictive of subsequent deterioration from sepsis within 72 h, and may be useful in determining disposition, but low lactate is not effective in screening stable patients at risk of deterioration.