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Roedl K, Fuhrmann V. [Liver diseases in the intensive care unit]. Med Klin Intensivmed Notfmed 2024:10.1007/s00063-024-01157-5. [PMID: 38937335 DOI: 10.1007/s00063-024-01157-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Accepted: 06/04/2024] [Indexed: 06/29/2024]
Abstract
The frequency of liver diseases in the intensive care unit has increased significantly in recent years and is now observed in up to 20% of critically ill patients. The occurrence of liver disease is associated with significantly increased morbidity and mortality. Two groups of liver diseases in the intensive care unit can be distinguished. First, the group of "primary hepatic dysfunctions", which includes primary acute liver failure as well as acute-on-chronic liver failure in patients with pre-existing liver cirrhosis. The second group of "secondary or acquired liver diseases" includes cholestatic liver diseases, as well as hypoxic liver injury and mixed forms, as well as other rarer liver diseases. Due to the diversity of liver diseases and the very different triggers, sufficient knowledge of the underlying changes (including hemodynamic changes, inflammatory states or drug-related) is essential. Early recognition, diagnosis, and treatment of the underlying disease are essential for all liver dysfunction in critically ill patients in the intensive care unit. This review article aims to take a closer look at liver diseases in the intensive care unit and provides insight into diagnostics and treatment options.
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Affiliation(s)
- Kevin Roedl
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - Valentin Fuhrmann
- Abteilung für Innere Medizin und Gastroenterologie, Heilig-Geist-Krankenhaus, Köln, Deutschland
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2
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Niu Z, Liu Y, Wang Y, Liu Y, Chai L, Wang H. Impairment of bile acid metabolism and altered composition by lead and copper in Bufo gargarizans tadpoles. THE SCIENCE OF THE TOTAL ENVIRONMENT 2023; 900:165901. [PMID: 37524187 DOI: 10.1016/j.scitotenv.2023.165901] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 07/10/2023] [Accepted: 07/28/2023] [Indexed: 08/02/2023]
Abstract
Lead (Pb) and copper (Cu) are two common heavy metal contaminants in environments, and liver is recognized as one of the main target organs for toxicity of Pb and Cu in animal organisms. Bile acids play a critical role in regulating hepatic metabolic homeostasis by activating farnesoid X receptor (Fxr). However, there were few studies on the interactions between bile acids and liver pathology caused by heavy metals. In this work, the histopathological changes, targeted metabolome and transcriptome responses in the liver of Bufo gargarizans tadpoles to Pb and/or Cu were examined. We found that exposure to Pb and/or Cu altered the hepatic bile acid profile, resulting in increased hydrophobicity and toxicity of the bile acid pool. And the expression of genes involved in bile acid metabolism and their downstream signaling pathways in the liver were significantly altered by Pb and/or Cu exposure. The alteration of bile acid profiles and the expression of genes related to bile acid metabolism might induce oxidative stress and inflammation, ultimately inducing hepatocyte injury observed in the histological sections. To our knowledge, this is the first study to provide histological, biochemical, and molecular evidence for establishing the link between Pb and Cu exposure, disturbances in hepatic bile acid metabolism, and liver injury.
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Affiliation(s)
- Ziyi Niu
- College of Life Science, Shaanxi Normal University, Xi'an 710119, China
| | - Yutian Liu
- State Key Laboratory of Pharmaceutical Biotechnology, School of Life Sciences, Nanjing University, Nanjing 210023, China
| | - Yaxi Wang
- College of Life Science, Shaanxi Normal University, Xi'an 710119, China
| | - Ying Liu
- College of Life Science, Shaanxi Normal University, Xi'an 710119, China
| | - Lihong Chai
- School of Water and Environment, Chang'an University, Xi'an 710054, China; Key Laboratory of Subsurface Hydrology and Ecological Effect in Arid Region of Ministry of Education, Chang'an University, Xi'an 710054, China
| | - Hongyuan Wang
- College of Life Science, Shaanxi Normal University, Xi'an 710119, China.
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3
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Chen J, Zhang S. The Role of Inflammation in Cholestatic Liver Injury. J Inflamm Res 2023; 16:4527-4540. [PMID: 37854312 PMCID: PMC10581020 DOI: 10.2147/jir.s430730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 10/06/2023] [Indexed: 10/20/2023] Open
Abstract
Cholestasis is a common clinical event in which bile formation and excretion are blocked, leading to retention of bile acids or bile salts; whether it occurs intra- or extrahepatically, primary or secondary, its pathogenesis is still unclear and is influenced by a combination of factors. In a variety of inflammatory and immune cells such as neutrophils, macrophages (intrahepatic macrophages are also known as Kupffer cells), mast cells, NK cells, and even T cells in humoral immunity and B cells in cellular immunity, inflammation can be a "second strike" against cholestatic liver injury. These cells, stimulated by a variety of factors such as bile acids, inflammatory chemokines, and complement, can be activated and accumulate in the cholestatic liver, and with the involvement of inflammatory mediators and modulation by cytokines, can lead to destruction of hepatocytes and bile duct epithelial cells and exacerbate (and occasionally retard) the progression of cholestatic liver disease. In this paper, we summarized the new research advances proposed so far regarding the relationship between inflammation and cholestasis, aiming to provide reference for researchers and clinicians in the field of cholestatic liver injury research.
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Affiliation(s)
- Jie Chen
- Chongqing Key Laboratory of Infectious Diseases and Parasitic Diseases, Department of Infectious Diseases, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
| | - Shujun Zhang
- Chongqing Key Laboratory of Infectious Diseases and Parasitic Diseases, Department of Infectious Diseases, the First Affiliated Hospital of Chongqing Medical University, Chongqing, People’s Republic of China
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4
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Bartoli A, Cursaro C, Seferi H, Andreone P. Secondary Sclerosing Cholangitis After SARS-CoV2: ICU Ketamine Use or Virus-Specific Biliary Tropism and Injury in the Context of Biliary Ischemia in Critically Ill Patients? Hepat Med 2023; 15:93-112. [PMID: 37547355 PMCID: PMC10404108 DOI: 10.2147/hmer.s384220] [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: 01/20/2023] [Accepted: 07/12/2023] [Indexed: 08/08/2023] Open
Abstract
Purpose From the beginning of the Severe Acute Respiratory Syndrome CoronaVirus-2 (SARS-CoV2) pandemic, different cases of a cholangiopathy with features of secondary sclerosing cholangitis in critically ill patients (SSC-CIP) have been reported. Patients developing it are generally recovering from severe Coronavirus disease 19 (COVID-19) and required intensive care unit (ICU) admission and mechanical ventilation. Many of them have been administered with ketamine during their ICU stay. The pathogenesis of this novel disease is still debated, and, since prognosis is poor, efforts are needed in order to better understand it. Patients and Methods In this review, we focused our attention on COVID-19 SSC clinical, imaging, and histology findings in order to clarify the different pathogenetic options, particularly in regard of the ischemic-direct viral damage and ketamine-related theories, beginning with a recapitulation of SSC-CIP and ketamine-induced cholangiopathy in abusers. The research has been conducted using PubMed and Google Scholar databases. Key-words were "Secondary Sclerosing Cholangiopathy", "SSC-CIP", "Secondary Sclerosing Cholangiopathy in critically ill patients", "Ketamine and cholangiopathy", "Ketamine abusers and liver disease", "Ketamine-related cholangiopathy", "SARS-CoV2 infection and liver disease", "post Covid-19 secondary sclerosing cholangitis", "Covid-19 cholangiopathy". Results Many authors, based on the clinical, histological, imaging, and prognostic features of the disease, have pointed out the similarities between post COVID-19 SSC and SSC-CIP; however, peculiar features in the former were not previously observed. Therefore, a direct viral cytopathic action and SARS-CoV2-related coagulopathy are considered the most likely causes. On the other hand, ketamine, with the available data, cannot be surely linked as the main determinant cause of cholangiopathy. Moreover, ketamine-induced cholangitis (KIC) presentation is different from post COVID-19 SSC. Its role as a cofactor precipitating the disease cannot be ruled out. Conclusion Post COVID-19 SSC is a rare clinical entity following severe COVID-19 disease. The most accepted theory is that a sum of different insults determines the disease: biliary ischemia, direct viral damage, toxic bile, possibly worsened by ketamine and hyperinflammation due to the cytokine storm. Given the severe prognosis of the disease, with persistent cholangiopathy, organ failure, and orthotopic liver transplantation (OLT), further study on this novel clinical entity is needed.
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Affiliation(s)
- Alessandra Bartoli
- Division of Internal Medicine and Metabolism, Department of Internal Medicine, Ospedale Civile di Baggiovara, University of Modena and Reggio Emilia, Modena, Italy
- Post Graduate School of Allergy and Clinical Immunology, Department of Internal Medicine, University of Modena and Reggio Emilia, Modena, Italy
| | - Carmela Cursaro
- Division of Internal Medicine and Metabolism, Department of Internal Medicine, Ospedale Civile di Baggiovara, University of Modena and Reggio Emilia, Modena, Italy
| | - Hajrie Seferi
- Division of Internal Medicine and Metabolism, Department of Internal Medicine, Ospedale Civile di Baggiovara, University of Modena and Reggio Emilia, Modena, Italy
| | - Pietro Andreone
- Chief of Division of Internal Medicine and metabolism, Department of Internal Medicine, University Hospital of Modena, Modena, Italy
- Chief of Post Graduate School of Allergy and Clinical Immunology, Department of Internal Medicine, University of Modena and Reggio Emilia, Modena, Italy
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Göth D, Mahler CF, Kälble F, Speer C, Benning L, Schmitt FCF, Dietrich M, Krautkrämer E, Zeier M, Merle U, Morath C, Fiedler MO, Weigand MA, Nusshag C. Liver-Support Therapies in Critical Illness-A Comparative Analysis of Procedural Characteristics and Safety. J Clin Med 2023; 12:4669. [PMID: 37510784 PMCID: PMC10380554 DOI: 10.3390/jcm12144669] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2023] [Revised: 07/09/2023] [Accepted: 07/11/2023] [Indexed: 07/30/2023] Open
Abstract
Extracorporeal liver-support therapies remain controversial in critically ill patients, as most studies have failed to show an improvement in outcomes. However, heterogeneous timing and inclusion criteria, an insufficient number of treatments, and the lack of a situation-dependent selection of available liver-support modalities may have contributed to negative study results. We retrospectively investigated the procedural characteristics and safety of the three liver-support therapies CytoSorb, Molecular Adsorbent Recirculating System (MARS) and therapeutic plasma exchange (TPE). Whereas TPE had its strengths in a shorter treatment duration, in clearing larger molecules, affecting platelet numbers less, and improving systemic coagulation and hemodynamics, CytoSorb and MARS were associated with a superior reduction in particularly small protein-bound and water-soluble substances. The clearance magnitude was concentration-dependent for all three therapies, but additionally related to the molecular weight for CytoSorb and MARS therapy. Severe complications did not appear. In conclusion, a better characterization of disease-driving as well as beneficial molecules in critically ill patients with acute liver dysfunction is crucial to improve the use of liver-support therapy in critically ill patients. TPE may be beneficial in patients at high risk for bleeding complications and impaired liver synthesis and hemodynamics, while CytoSorb and MARS may be considered for patients in whom the elimination of smaller toxic compounds is a primary objective.
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Affiliation(s)
- Daniel Göth
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Christoph F Mahler
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Florian Kälble
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Claudius Speer
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Louise Benning
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Felix C F Schmitt
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Maximilian Dietrich
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Ellen Krautkrämer
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Martin Zeier
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Uta Merle
- Department of Gastroenterology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Christian Morath
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Mascha O Fiedler
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Markus A Weigand
- Department of Anesthesiology, Heidelberg University Hospital, 69120 Heidelberg, Germany
| | - Christian Nusshag
- Department of Nephrology, Heidelberg University Hospital, 69120 Heidelberg, Germany
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Perez Ruiz de Garibay A, Kortgen A, Leonhardt J, Zipprich A, Bauer M. Critical care hepatology: definitions, incidence, prognosis and role of liver failure in critically ill patients. Crit Care 2022; 26:289. [PMID: 36163253 PMCID: PMC9511746 DOI: 10.1186/s13054-022-04163-1] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 09/10/2022] [Indexed: 01/11/2023] Open
Abstract
AbstractOrgan 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
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7
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Alnamshan MM. Potential histopathological and immunological effects of SARS-CoV-2 on the liver. BRAZ J BIOL 2022; 82:e262008. [PMID: 36074418 DOI: 10.1590/1519-6984.262008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Accepted: 07/05/2022] [Indexed: 12/15/2022] Open
Abstract
The coronavirus disease outbreak of 2019 (COVID-19) poses a serious threat to public health worldwide. Lung injury is the most common complication of Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) infection. However, other organs, including the liver, can also be affected. Currently, there is limited evidence that liver impairment is associated with severe SARS-CoV-2 infection. Clinicians will need to determine whether liver injury is caused by an underlying liver condition, COVID-19 therapy, the virus directly, or immune-mediated inflammation or represents a complicated disease course in the context of COVID-19. To address the scarcity of data on histopathological changes and immunological effects on the liver with COVID-19 positivity, we analyze and summarize recent findings. We searched PubMed, Medline, Google Scholar, Science Direct, Scopus, and Web of Science databases up to December 1, 2021, identifying published studies with the search terms "Histopathology in COVID-19," "COVID-19," "Pathological changes in liver in COVID-19," "Liver pathology in COVID-19," "immunological effects in liver in COVID-19," and "SARS-CoV-2." This concise review will aid clinicians and researchers in better understanding the tissue histopathology and immunological consequences of SARS-CoV-2 on the liver, enabling improved care planning and avoiding future dangers.
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Affiliation(s)
- M M Alnamshan
- Imam Abdulrahman Bin Faisal University, College of Science, Department of Biology, Dammam, Saudi Arabia
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8
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Prediction Model of Adverse Effects on Liver Functions of COVID-19 ICU Patients. JOURNAL OF HEALTHCARE ENGINEERING 2022; 2022:4584965. [PMID: 35480158 PMCID: PMC9036165 DOI: 10.1155/2022/4584965] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/03/2021] [Accepted: 04/09/2022] [Indexed: 12/15/2022]
Abstract
SARS-CoV-2 is a recently discovered virus that poses an urgent threat to global health. The disease caused by this virus is termed COVID-19. Death tolls in different countries remain to rise, leading to continuous social distancing and lockdowns. Patients of different ages are susceptible to severe disease, in particular those who have been admitted to an ICU. Machine learning (ML) predictive models based on medical data patterns are an emerging topic in areas such as the prediction of liver diseases. Prediction models that combine several variables or features to estimate the risk of people being infected or experiencing a poor outcome from infection could assist medical staff in the treatment of patients, especially those that develop organ failure such as that of the liver. In this paper, we propose a model called the detecting model for liver damage (DMLD) that predicts the risk of liver damage in COVID-19 ICU patients. The DMLD model applies machine learning algorithms in order to assess the risk of liver failure based on patient data. To assess the DMLD model, collected data were preprocessed and used as input for several classifiers. SVM, decision tree (DT), Naïve Bayes (NB), KNN, and ANN classifiers were tested for performance. SVM and DT performed the best in terms of predicting illness severity based on laboratory testing.
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9
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Chen W, Liu H, Yang G, Wang W, Liu Q, Huang C, Zou Z, Liu Y, Zhuang G, Zhang L. Effect of Direct Bilirubin Level on Clinical Outcome and Prognoses in Severely/Critically Ill Patients With COVID-19. Front Med (Lausanne) 2022; 9:843505. [PMID: 35419371 PMCID: PMC8996189 DOI: 10.3389/fmed.2022.843505] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 03/02/2022] [Indexed: 11/25/2022] Open
Abstract
Objectives We aimed to investigate how changes in direct bilirubin (DBiL) levels in severely/critically ill the coronavirus disease (COVID-19) patients during their first week of hospital admission affect their subsequent prognoses and mortality. Methods We retrospectively enrolled 337 severely/critically ill COVID-19 patients with two consecutive blood tests at hospital admission and about 7 days after. Based on the trend of the two consecutive tests, we categorized patients into the normal direct bilirubin (DBiL) group (224), declined DBiL group (44) and elevated DBiL group (79). Results The elevated DBiL group had a significantly larger proportion of critically ill patients (χ2-test, p < 0.001), a higher risk of ICU admission, respiratory failure, and shock at hospital admission (χ2-test, all p < 0.001). During hospitalization, the elevated DBiL group had significantly higher risks of shock, acute respiratory distress syndrome (ARDS), and respiratory failure (χ2-test, all p < 0.001). The same findings were observed for heart damage (χ2-test, p = 0.002) and acute renal injury (χ2-test, p = 0.009). Cox regression analysis showed the risk of mortality in the elevated DBiL group was 2.27 (95% CI: 1.50–3.43, p < 0.001) times higher than that in the normal DBiL group after adjusted age, initial symptom, and laboratory markers. The Receiver Operating Characteristic curve (ROC) analysis demonstrated that the second test of DBiL was consistently a better indicator of the occurrence of complications (except shock) and mortality than the first test in severely/critically ill COVID-19 patients. The area under the ROC curve (AUC) combined with two consecutive DBiL levels for respiratory failure and death was the largest. Conclusion Elevated DBiL levels are an independent indicator for complication and mortality in COVID-19 patients. Compared with the DBiL levels at admission, DBiL levels on days 7 days of hospitalization are more advantageous in predicting the prognoses of COVID-19 in severely/critically ill patients.
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Affiliation(s)
- Wensen Chen
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China.,Office of Infection Management, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Hanting Liu
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, China
| | - Gang Yang
- Department of Cardiology, Jiangsu Province Hospital, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Wei Wang
- Department of Information Management, Wuhan No. 1 Hospital, Wuhan, China
| | - Qiongfang Liu
- Department of Infection Management, Wuhan Hankou Hospital, Wuhan, China
| | - Chaolin Huang
- Center for Translational Medicine, Wuhan Jinyintan Hospital, Wuhan, China
| | - Zhuoru Zou
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, China
| | - Yun Liu
- School of Biomedical Engineering and Informatics, Nanjing Medical University, Nanjing, China
| | - Guihua Zhuang
- Department of Epidemiology and Biostatistics, School of Public Health, Xi'an Jiaotong University Health Science Center, Xi'an, China.,China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, China
| | - Lei Zhang
- China-Australia Joint Research Centre for Infectious Diseases, School of Public Health, Xi'an Jiaotong University Health Science Centre, Xi'an, China.,Faculty of Medicine, Nursing and Health Sciences, Central Clinical School, Monash University, Melbourne, VIC, Australia.,Melbourne Sexual Health Centre, Alfred Health, Melbourne, VIC, Australia
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10
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Duan R, Huang K, Guan X, Li S, Xia J, Shen M, Sun Z, Yu Z. Tectorigenin ameliorated high-fat diet-induced nonalcoholic fatty liver disease through anti-inflammation and modulating gut microbiota in mice. Food Chem Toxicol 2022; 164:112948. [PMID: 35390440 DOI: 10.1016/j.fct.2022.112948] [Citation(s) in RCA: 19] [Impact Index Per Article: 9.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2022] [Revised: 03/12/2022] [Accepted: 03/17/2022] [Indexed: 12/14/2022]
Abstract
Nonalcoholic fatty liver disease (NAFLD) is a complex pathogenesis of liver disease combined with liver inflammation and gut microbiota dysbiosis. Tectorigenin (Tg) is derived from many plants with excellent anti-inflammation activity. However, the beneficial effect of Tg on NAFLD associated with gut microbiota remained unclear. This study aimed to investigate the underlying beneficial effect of Tg on NAFLD in high-fat diet (HFD)-fed mice. Results showed that Tg alleviated lipid profiles and liver steatosis, and reduced serum lipopolysaccharide (LPS) and total bile acid (TBA) levels. Besides, RT-qPCR and Western blot suggested that Tg alleviated hepatic lipid accumulation through inhibiting the lipogenesis and promoting the lipolysis, prevented gut-derived LPS-induced liver inflammatory via restoring intestinal barrier and restraining pro-inflammatory cytokines release, meanwhile, promoted the BA circulation via activating BA receptor and promoting BA synthesis. Moreover, Tg reverted the HFD-induced gut microbial dysbiosis by promoting the growth of beneficial Akkermansia, and inhibiting the proportions of harmful microbes, including Blautia, Lachnoclostridium, Lachnospiraceae_UCG-006, Roseburia, Romboutsia and Faecalibaculum, which were highly correlated with NAFLD-related parameters in serum and liver. Thus, Tg could attenuate NAFLD through mediating the liver-gut axis, and it could be used as a dietary supplement for NAFLD treatment via its anti-inflammatory and prebiotic effects.
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Affiliation(s)
- Ruiqian Duan
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, PR China; National Grain Industry (Urban Grain and Oil Security) Technology Innovation Center, Shanghai, PR China
| | - Kai Huang
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, PR China; National Grain Industry (Urban Grain and Oil Security) Technology Innovation Center, Shanghai, PR China
| | - Xiao Guan
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, PR China; National Grain Industry (Urban Grain and Oil Security) Technology Innovation Center, Shanghai, PR China.
| | - Sen Li
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, PR China; National Grain Industry (Urban Grain and Oil Security) Technology Innovation Center, Shanghai, PR China
| | - Ji'an Xia
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, PR China; National Grain Industry (Urban Grain and Oil Security) Technology Innovation Center, Shanghai, PR China
| | - Meng Shen
- School of Health Science and Engineering, University of Shanghai for Science and Technology, Shanghai, PR China; National Grain Industry (Urban Grain and Oil Security) Technology Innovation Center, Shanghai, PR China
| | - Zhu Sun
- Inner Mongolia Yangufang Ecological Agricultural Science and Technology (Group) Co., Ltd, Inner Mongolia, PR China
| | - Zhiquan Yu
- Inner Mongolia Yangufang Ecological Agricultural Science and Technology (Group) Co., Ltd, Inner Mongolia, PR China
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11
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Wang S, Sheng F, Zou L, Xiao J, Li P. Hyperoside attenuates non-alcoholic fatty liver disease in rats via cholesterol metabolism and bile acid metabolism. J Adv Res 2022; 34:109-122. [PMID: 35024184 PMCID: PMC8655136 DOI: 10.1016/j.jare.2021.06.001] [Citation(s) in RCA: 50] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/19/2021] [Revised: 06/03/2021] [Accepted: 06/04/2021] [Indexed: 02/05/2023] Open
Abstract
Introduction Non-alcoholic fatty liver disease (NAFLD) results from increased hepatic total cholesterol (TC) and total triglyceride (TG) accumulation. In our previous study, we found that rats treated with hyperoside became resistant to hepatic lipid accumulation. Objectives The present study aims to investigate the possible mechanisms responsible for the inhibitory effects of hyperoside on the lipid accumulation in the liver tissues of the NAFLD rats. Methods Label-free proteomics and metabolomics targeting at bile acid (BA) metabolism were applied to disclose the mechanisms for hyperoside reducing hepatic lipid accumulation among the NAFLD rats. Results In response to hyperoside treatment, several proteins related to the fatty acid degradation pathway, cholesterol metabolism pathway, and bile secretion pathway were altered, including ECI1, Acnat2, ApoE, and BSEP, etc. The expression of nuclear receptors (NRs), including farnesoid X receptor (FXR) and liver X receptor α (LXRα), were increased in hyperoside-treated rats' liver tissue, accompanied by decreased protein expression of catalyzing enzymes in the hepatic de novo lipogenesis and increased protein level of enzymes in the classical and alternative BA synthetic pathway. Liver conjugated BAs were less toxic and more hydrophilic than unconjugated BAs. The BA-targeted metabolomics suggest that hyperoside could decrease the levels of liver unconjugated BAs and increase the levels of liver conjugated BAs. Conclusions Taken together, the results suggest that hyperoside could improve the condition of NAFLD by regulating the cholesterol metabolism as well as BAs metabolism and excretion. These findings contribute to understanding the mechanisms by which hyperoside lowers the cholesterol and triglyceride in NAFLD rats.
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Key Words
- ACC, Acetyl-CoA carboxylase
- AMPK, AMP-activated protein kinase
- Apo, apolipoprotein
- BAs, bile acids
- BSH, bile salt hydrolase
- Bile acid metabolism
- CYP27A1, sterol 27-hydroxylase
- CYP7A1, cholesterol 7α-hydroxylase
- Cholesterol metabolism
- FGF15/19, fibroblast growth factor 15/19
- FXR, farnesoid X receptor
- Hyperoside
- LC-MS, the combination of high-performance liquid chromatography and mass spectrometry
- LXRα, liver X receptor α
- Label-free proteomics
- NAFLD
- NAFLD, non-alcoholic fatty liver disease
- PMSF, phenylmethylsulfonyl fluoride
- QC, quality control
- SDS, sodium dodecyl sulfate
- SHP, small heterodimer partner
- SREBP1, sterol regulatory element-binding protein 1
- SREBP2, sterol regulatory element-binding protein 2
- SREBPs, sterol regulatory element binding proteins
- TC, total cholesterol
- TG, triglyceride
- TGR5, Takeda G-protein-coupled receptor 5
- Targeted metabolomics
- VLDL, very low-density lipoprotein
- WB, Western blot
- pACC, phosphorylated ACC
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Affiliation(s)
- Songsong Wang
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao 999078, China
| | - Feiya Sheng
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao 999078, China
| | - Liang Zou
- School of Medicine, Chengdu University, Chengdu 610106, China
| | - Jianbo Xiao
- Institute of Food Safety and Nutrition, Jinan University, Guangzhou 510632, China.,Department of Analytical Chemistry and Food Science, Faculty of Food Science and Technology, University of Vigo, Vigo, Spain
| | - Peng Li
- State Key Laboratory of Quality Research in Chinese Medicine, Institute of Chinese Medical Sciences, University of Macau, Macao 999078, China
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12
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Tampe D, Korsten P, Bremer SCB, Winkler MS, Tampe B. Kinetics of Bilirubin and Ammonia Elimination during Hemadsorption Therapy in Secondary Sclerosing Cholangitis Following ECMO Therapy and Severe COVID-19. Biomedicines 2021; 9:biomedicines9121841. [PMID: 34944657 PMCID: PMC8698542 DOI: 10.3390/biomedicines9121841] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2021] [Revised: 12/03/2021] [Accepted: 12/04/2021] [Indexed: 12/14/2022] Open
Abstract
In critically ill patients, liver dysfunction often results in coagulopathy and encephalopathy and is associated with high mortality. Extracorporeal clearance of hepatotoxic metabolites, including bilirubin and ammonia, aims to attenuate further hepatocyte damage and liver injury, resulting in decreased mortality. The efficacy of hemadsorption combined with conventional hemodialysis to eliminate bilirubin and ammonia to support the liver's excretory function in acute liver injury has been described previously. However, the optimal use of liver support systems in chronic liver dysfunction due to secondary sclerosing cholangitis in critically ill patients (SSC-CIP) has not been defined yet. We herein describe the kinetics of successful bilirubin and ammonia elimination by hemadsorption in a patient with SSC-CIP after extracorporeal membrane oxygenation (ECMO) therapy for severe acute respiratory distress syndrome (ARDS) in a patient with coronavirus disease 2019 (COVID-19). During the course of the disease, the patient developed laboratory signs of liver injury during ECMO therapy before clinically detectable jaundice or elevated bilirubin levels. A diagnosis of SSC-CIP was confirmed by endoscopic retrograde cholangiopancreatography (ERCP) based on intraductal filling defects in the intrahepatic bile ducts due to biliary casts. The patient showed stable elevations of bilirubin and ammonia levels thereafter, but presented with progressive nausea, vomiting, weakness, and exhaustion. Based on these laboratory findings, hemadsorption was combined with hemodialysis treatment and successfully eliminated bilirubin and ammonia. Moreover, direct comparison revealed that ammonia is more efficiently eliminated by hemadsorption than bilirubin levels. Clinical symptoms of nausea, vomiting, weakness, and exhaustion improved. In summary, bilirubin and ammonia were successfully eliminated by hemadsorption combined with hemodialysis treatment in SSC-CIP following ECMO therapy and severe COVID-19. This observation is particularly relevant since it has been reported that a considerable subset of critically ill patients with COVID-19 suffer from liver dysfunction associated with high mortality.
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Affiliation(s)
- Désirée Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, 37075 Göttingen, Germany; (D.T.); (P.K.)
| | - Peter Korsten
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, 37075 Göttingen, Germany; (D.T.); (P.K.)
| | - Sebastian C. B. Bremer
- Department of Gastroenterology, Gastrointestinal Oncology and Endocrinology, University Medical Center Göttingen, 37075 Göttingen, Germany;
| | - Martin S. Winkler
- Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, 37075 Göttingen, Germany;
| | - Björn Tampe
- Department of Nephrology and Rheumatology, University Medical Center Göttingen, 37075 Göttingen, Germany; (D.T.); (P.K.)
- Correspondence: ; Tel.: +49-551-39-10575
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13
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Secondary Hepatic Injury in Pediatric Intensive Care: Risk Factors and Prognostic Impact. J Pediatr Gastroenterol Nutr 2021; 73:471-477. [PMID: 34117196 DOI: 10.1097/mpg.0000000000003199] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
OBJECTIVES The aim of this study was to assess the profile of secondary hepatic injury (SHI), to determine risk factors and to evaluate its impact on prognosis of pediatric intensive care patients. METHODS An exploratory observational and retrospective study was conducted in a Pediatric Intensive Care Unit. Two groups were defined: with SHI [alanine aminotransferase (ALT) ≥100 IU/L or gamma glutamyl transpeptidase (GGT)≥100 IU/L or direct bilirubin ≥30 μmol/L] and without. SHI was divided into 3 patterns: cytolysis, cholestasis, and mixed. RESULTS SHI occurred in 16.5%, cytolysis in 5%, cholestasis in 4%, and mixed pattern in 7%. Independent risk factors for SHI were: organ dysfunction score PELOD-2 in D1 in cytolysis (n = 28); total parenteral nutrition and Pediatric Index of Mortality 3 (PIM3) in cholestasis (n = 23); sepsis, oncologic comorbidities, PIM3, and respiratory dysfunction in mixed pattern (n = 37). The ALT was an independent risk factor and a good predictor of mortality (AUC = 0.865) with a cut-off of 137 IU/L. CONCLUSIONS SHI was associated with worst prognostic. ALT may be useful for detecting patients at increased risk of death, probably being a surrogate marker of the illness severity, reflecting a secondary injury.
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14
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Bütikofer S, Lenggenhager D, Wendel Garcia PD, Maggio EM, Haberecker M, Reiner CS, Brüllmann G, Buehler PK, Gubler C, Müllhaupt B, Jüngst C, Morell B. Secondary sclerosing cholangitis as cause of persistent jaundice in patients with severe COVID-19. Liver Int 2021; 41:2404-2417. [PMID: 34018314 PMCID: PMC8242687 DOI: 10.1111/liv.14971] [Citation(s) in RCA: 49] [Impact Index Per Article: 16.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Revised: 05/16/2021] [Accepted: 05/18/2021] [Indexed: 01/08/2023]
Abstract
BACKGROUND & AIMS Little is known about cholestasis, including its most severe variant secondary sclerosing cholangitis (SSC), in critically ill patients with coronavirus disease 19 (COVID-19). In this study, we analysed the occurrence of cholestatic liver injury and SSC, including clinical, serological, radiological and histopathological findings. METHODS We conducted a retrospective single-centre analysis of all consecutive patients admitted to the intensive care unit (ICU) as a result of severe COVID-19 at the University Hospital Zurich to describe cholestatic injury in these patients. The findings were compared to a retrospective cohort of patients with severe influenza A. RESULTS A total of 34 patients with severe COVID-19 admitted to the ICU were included. Of these, 14 patients (41%) had no cholestasis (group 0), 11 patients (32%, group 1) developed mild and 9 patients (27%, group 2) severe cholestasis. Patients in group 2 had a more complicated disease course indicated by significantly longer ICU stay (median 51 days, IQR 25-86.5) than the other groups (group 0: median 9.5 days, IQR 3.8-18.3, P = .001; and group 1: median 16 days, IQR 8-30, P < .05 respectively). Four patients in group 2 developed SSC compared to none in the influenza A cohort. The available histopathological findings suggest an ischaemic damage to the perihilar bile ducts. CONCLUSIONS The development of SSC represents an important complication of critically ill COVID-19 patients and needs to be considered in the diagnostic work up in prolonged cholestasis. The occurrence of SSC is of interest in the ongoing pandemic since it is associated with considerable morbidity and mortality.
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Affiliation(s)
- Simon Bütikofer
- Department of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
| | - Daniela Lenggenhager
- Department of Pathology and Molecular PathologyUniversity Hospital ZurichZurichSwitzerland
| | | | - Ewerton M. Maggio
- Department of Pathology and Molecular PathologyUniversity Hospital ZurichZurichSwitzerland
| | - Martina Haberecker
- Department of Pathology and Molecular PathologyUniversity Hospital ZurichZurichSwitzerland
| | - Cäcilia S. Reiner
- Institute of Diagnostic and Interventional RadiologyUniversity Hospital ZurichZurichSwitzerland
| | - Gregor Brüllmann
- Institute of Intensive CareUniversity Hospital ZurichZurichSwitzerland
| | | | - Christoph Gubler
- Department of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
| | - Beat Müllhaupt
- Department of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
| | - Christoph Jüngst
- Department of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
| | - Bernhard Morell
- Department of Gastroenterology and HepatologyUniversity Hospital ZurichZurichSwitzerland
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15
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Evaluating mortality and recovery of extreme hyperbilirubinemia in critically ill patients by phasing the peak bilirubin level: A retrospective cohort study. PLoS One 2021; 16:e0255230. [PMID: 34351969 PMCID: PMC8341602 DOI: 10.1371/journal.pone.0255230] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2020] [Accepted: 07/12/2021] [Indexed: 01/12/2023] Open
Abstract
Background Hyperbilirubinemia is a devastating complication in patients admitted to an intensive care unit (ICU). The sequential organ failure assessment (SOFA) score classifies hyperbilirubinemia without further detailed analyses for bilirubin increase above 12 mg/dL. We evaluated whether the level of bilirubin increase in patients with extreme hyperbilirubinemia (total bilirubin ≥ 12 mg/dL) affects and also helps estimate mortality or recovery. Methods A retrospective cohort analysis comprising 427 patients with extreme hyperbilirubinemia admitted to the ICU of Samsung Medical Center, Seoul, Korea between 2011 and 2015 was conducted. Extreme hyperbilirubinemia was classified into four grades: grade 1 (12–14.9 mg/dL), grade 2 (15–19.9 mg/dL), grade 3 (20–29.9 mg/dL), and grade 4 (≥ 30 mg/dL). These grades were then assessed for their association with hospital mortality and recovery from hyperbilirubinemia to SOFA grade (point) 2 or below (total bilirubin < 6 mg/dL). The influences of various factors, some of which caused extreme hyperbilirubinemia, while others induced bilirubin recovery, were assessed. Results A total of 427 patients (mean age: 59.8 years, male: 67.0%) were evaluated, and the hospital mortality for these patients was very high (76.1%). Extreme hyperbilirubinemia was observed in 111 (grade 1, 26.0%), 99 (grade 2, 23.2%), 131 (grade3, 30.7%), and 86 (grade 4, 20.1%) patients with mortality rates of 62.2%, 71.7%, 81.7%, and 90.7%, respectively (p < 0.001). The peak bilirubin value correlated with the mortality (odds ratio [OR], 1.09; 95% confidence interval [CI], 1.04–1.15, p < 0.001). Compared to those with grade 1 extreme hyperbilirubinemia, the mortality rate gradually increased as the grade increased (OR [95% CI]: 1.92 [0.70–5.28], 3.55 [1.33–9.48], and 12.47 [3.07–50.59] for grades 2, 3 and 4, respectively). The main causes of extreme hyperbilirubinemia were infection including sepsis and hypoxic hepatitis. The recovery from hyperbilirubinemia was observed in 110 (25.8%) patients. Mortality was lower for those who recovered from hyperbilirubinemia than for those who did not (29.1% vs. 92.4%, p < 0.001). The favorable factors of bilirubin recovery were albumin and ursodeoxycholic acid (UDCA). Conclusions This study determined that the level of extreme hyperbilirubinemia is an important prognostic factor in critically ill patients. We expect the results of this study to help predict the clinical course of and determine the optimal treatment for extreme hyperbilirubinemia.
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16
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Scharf C, Liebchen U, Paal M, Becker-Pennrich A, Irlbeck M, Zoller M, Schroeder I. Successful elimination of bilirubin in critically ill patients with acute liver dysfunction using a cytokine adsorber and albumin dialysis: a pilot study. Sci Rep 2021; 11:10190. [PMID: 33986443 PMCID: PMC8119427 DOI: 10.1038/s41598-021-89712-4] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/29/2021] [Indexed: 12/15/2022] Open
Abstract
There are different methods of artificial liver support for patients with acute liver dysfunction (ALD). However, CytoSorb (CS) might be a new approved option for those patients. Question of interest is whether the elimination performance of CS was comparable to that of advanced organ support (ADVOS). Patients, treated with CS (integrated into high-flux dialysis) or ADVOS and a total bilirubin > 10 mg/dl were included. Laboratory parameters were evaluated before starting therapy (d0) and 12–24 h thereafter (d1). The Wilcoxon-test with associated samples was used for statistical analysis. Thirty-nine patients (33 CS, 6 ADVOS) were included. The median bilirubin at d0 was 16.9 and 17.7 mg/dl and at d1 was 13.2 and 15.9 mg/dl, in the CS and ADVOS group, respectively. There was a significant bilirubin reduction as well in the CS group (p < 0.001, median relative reduction: 22.5%) as in the ADVOS group (p = 0.028, median relative reduction: 22.8%). There was no significant difference in the relative bilirubin reduction between CS and ADVOS therapies. The use of CytoSorb and ADVOS in patients with ALD led to a significant and comparable decrease in total bilirubin. The easy use of CS might be an advantage compared to other procedures.
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Affiliation(s)
- Christina Scharf
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany.
| | - Uwe Liebchen
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Paal
- Institute of Laboratory Medicine, LMU Hospital, Munich, Germany
| | - Andrea Becker-Pennrich
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Irlbeck
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Michael Zoller
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
| | - Ines Schroeder
- Department of Anesthesiology, LMU Hospital, Marchioninistrasse 15, 81377, Munich, Germany
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17
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Roedl K, Jarczak D, Drolz A, Wichmann D, Boenisch O, de Heer G, Burdelski C, Frings D, Sensen B, Nierhaus A, Lütgehetmann M, Kluge S, Fuhrmann V. Severe liver dysfunction complicating course of COVID-19 in the critically ill: multifactorial cause or direct viral effect? Ann Intensive Care 2021; 11:44. [PMID: 33721137 PMCID: PMC7957439 DOI: 10.1186/s13613-021-00835-3] [Citation(s) in RCA: 13] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 03/05/2021] [Indexed: 01/08/2023] Open
Abstract
Background SARS-CoV-2 caused a pandemic and global threat for human health. Presence of liver injury was commonly reported in patients with coronavirus disease 2019 (COVID-19). However, reports on severe liver dysfunction (SLD) in critically ill with COVID-19 are lacking. We evaluated the occurrence, clinical characteristics and outcome of SLD in critically ill patients with COVID-19. Methods Clinical course and laboratory was analyzed from all patients with confirmed COVID-19 admitted to ICU of the university hospital. SLD was defined as: bilirubin ≥ 2 mg/dl or elevation of aminotransferase levels (> 20-fold ULN). Results 72 critically ill patients were identified, 22 (31%) patients developed SLD. Presenting characteristics including age, gender, comorbidities as well as clinical presentation regarding COVID-19 overlapped substantially in both groups. Patients with SLD had more severe respiratory failure (paO2/FiO2: 82 (58–114) vs. 117 (83–155); p < 0.05). Thus, required more frequently mechanical ventilation (95% vs. 64%; p < 0.01), rescue therapies (ECMO) (27% vs. 12%; p = 0.106), vasopressor (95% vs. 72%; p < 0.05) and renal replacement therapy (86% vs. 30%; p < 0.001). Severity of illness was significantly higher (SAPS II: 48 (39–52) vs. 40 (32–45); p < 0.01). Patients with SLD and without presented viremic during ICU stay in 68% and 34%, respectively (p = 0.002). Occurrence of SLD was independently associated with presence of viremia [OR 6.359; 95% CI 1.336–30.253; p < 0.05] and severity of illness (SAPS II) [OR 1.078; 95% CI 1.004–1.157; p < 0.05]. Mortality was high in patients with SLD compared to other patients (68% vs. 16%, p < 0.001). After adjustment for confounders, SLD was independently associated with mortality [HR3.347; 95% CI 1.401–7.999; p < 0.01]. Conclusion One-third of critically ill patients with COVID-19 suffer from SLD, which is associated with high mortality. Occurrence of viremia and severity of illness seem to contribute to occurrence of SLD and underline the multifactorial cause. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00835-3.
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Affiliation(s)
- Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Andreas Drolz
- Department of Internal Medicine I, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Dominic Wichmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Olaf Boenisch
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Geraldine de Heer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Christoph Burdelski
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Daniel Frings
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Barbara Sensen
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Marc Lütgehetmann
- Institute of Medical Microbiology, Virology and Hygiene, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
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18
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Lin J, Gu C, Zhang S, Tian L, Ren K, Cao Z, Han X. Sites and Causes of Infection in Patients with Sepsis-Associated Liver Dysfunction: A Population Study from the Medical Information Mart for Intensive Care III. Med Sci Monit 2021; 27:e928928. [PMID: 33638975 PMCID: PMC7927361 DOI: 10.12659/msm.928928] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2020] [Accepted: 12/17/2020] [Indexed: 11/09/2022] Open
Abstract
BACKGROUND Little is known about the relationship between the site of infection, type of pathogen, and the occurrence of sepsis-associated liver dysfunction (SALD). This population study aimed to identify the sites and types of infection in SALD patients. MATERIAL AND METHODS We conducted a retrospective observational study using the Medical Information Mart for Intensive Care III. Patients with sepsis were divided into a SALD group and a control group. We evaluated the effect of the location of culture-positive specimens and the distribution of pathogens on the occurrence of SALD and then compared the clinical outcomes. RESULTS A total of 14 596 admissions were included, and the incidence of SALD was 11.96%. Positive bile culture (odds ratio [OR] 7.450, P<0.001), peritoneal fluid culture (OR 3.616, P<0.001), and blood culture (OR 1.957, P<0.001) were correlated with the occurrence of SALD. Infection with Enterococcus faecium (OR 3.065, P<0.001), Bacteroides fragilis (OR 2.061, P<0.001), Klebsiella oxytoca (OR 2.066, P<0.001), Enterobacter aerogenes (OR 1.92, P=0.001), and Aspergillus fumigatus (OR 2.144, P=0.001) were correlated with the occurrence of SALD. The Intensive Care Unit mortality and hospital mortality were higher in the SALD group than in the control group (24.7% vs 9.0%, P<0.001; 34.2% vs 13.8%, P<0.001, respectively). CONCLUSIONS SALD should be considered for patients with sepsis whose infection site is the biliary system, abdominal cavity, or blood and the pathogen is Enterococcus faecium, B. fragilis, K. oxytoca, Enterobacter aerogenes, or A. fumigatus. When SALD occurs in patients with sepsis, the above infection sites and pathogens should be considered first.
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Affiliation(s)
- Jinfeng Lin
- Critical Care Medicine, Nantong Third People’s Hospital, Nantong University, Nantong, Jiangsu, P.R. China
| | - Chunfeng Gu
- Ctrip Infrastructure Service, Trip.com Group Ltd., Nantong, Jiangsu, P.R. China
| | - Suyan Zhang
- Critical Care Medicine, Nantong Third People’s Hospital, Nantong University, Nantong, Jiangsu, P.R. China
| | - Lijun Tian
- Critical Care Medicine, Nantong Third People’s Hospital, Nantong University, Nantong, Jiangsu, P.R. China
| | - Ke Ren
- Critical Care Medicine, Nantong Third People’s Hospital, Nantong University, Nantong, Jiangsu, P.R. China
| | - Zhilong Cao
- Critical Care Medicine, Nantong Third People’s Hospital, Nantong University, Nantong, Jiangsu, P.R. China
| | - Xudong Han
- Critical Care Medicine, Nantong Third People’s Hospital, Nantong University, Nantong, Jiangsu, P.R. China
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19
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Noroozi B, Hadi A, Shahrami B, Ardabili A, Yoonesi F, Emami K, Sharifnia H, Mojtahedzadeh M. Sepsis-Associated Cholestasis: The Impact of Mitochondrial Dysfunction (A Case Report). ACTA ACUST UNITED AC 2021. [DOI: 10.37319/iqnjm.3.1.5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Introduction: Hyperbilirubinemia – a condition of elevated serum bilirubin above the reference
range, is common in hospitalized patients. The reasons for the increase in the bilirubin level can
be pre-hepatic, hepatic, and post-hepatic. Sepsis is one of the most important causes of
hyperbilirubinemia in critically ill patients.
Case report: We present a 30-year-old woman with no past medical and drug history who was
admitted to the intensive care unit (ICU) due to multiple trauma and fractures due to a fall from
height. During the ICU stay, the patient developed jaundice with a high increase in the bilirubin
level. A diagnosis of sepsis-associated cholestasis was considered after ruling out other possible
pathologies. The hyperbilirubinemia improved with the early management of sepsis concomitant
supportive medical therapy.
Conclusion: Early recognition and treatment of sepsis as a cause of cholestasis should be
considered in ICU patients. Drugs targeting mitochondrial function would provide rapid hepatic
recovery reducing complications and mortality.
Keywords: Cholestasis, Critical illness, Hyperbilirubinemia, Liver failure, Sepsis
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Affiliation(s)
- Behzad Noroozi
- Clinical Pharmacy Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Ali Hadi
- Clinical Pharmacy Department, College of Pharmacy, University of Basra, Basra, Iraq
| | - Bita Shahrami
- Clinical Pharmacy Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Ayda Ardabili
- Anesthesiology and Intensive Care Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Fatemeh Yoonesi
- Anesthesiology and Intensive Care Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Kaveh Emami
- Anesthesiology and Intensive Care Department, Tehran University of Medical Sciences, Tehran, Iran
| | - Hamid Sharifnia
- Anesthesiology and Intensive Care Department, Tehran University of Medical Sciences, Tehran, Iran
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20
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Nardo AD, Schneeweiss‐Gleixner M, Bakail M, Dixon ED, Lax SF, Trauner M. Pathophysiological mechanisms of liver injury in COVID-19. Liver Int 2021; 41:20-32. [PMID: 33190346 PMCID: PMC7753756 DOI: 10.1111/liv.14730] [Citation(s) in RCA: 229] [Impact Index Per Article: 76.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 11/05/2020] [Accepted: 11/06/2020] [Indexed: 02/06/2023]
Abstract
The recent outbreak of coronavirus disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has resulted in a world-wide pandemic. Disseminated lung injury with the development of acute respiratory distress syndrome (ARDS) is the main cause of mortality in COVID-19. Although liver failure does not seem to occur in the absence of pre-existing liver disease, hepatic involvement in COVID-19 may correlate with overall disease severity and serve as a prognostic factor for the development of ARDS. The spectrum of liver injury in COVID-19 may range from direct infection by SARS-CoV-2, indirect involvement by systemic inflammation, hypoxic changes, iatrogenic causes such as drugs and ventilation to exacerbation of underlying liver disease. This concise review discusses the potential pathophysiological mechanisms for SARS-CoV-2 hepatic tropism as well as acute and possibly long-term liver injury in COVID-19.
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Affiliation(s)
- Alexander D. Nardo
- Hans Popper Laboratory of Molecular HepatologyDivision of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Mathias Schneeweiss‐Gleixner
- Medical Intensive Care Unit 13H1. Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - May Bakail
- Campus ITInstitute of Science and Technology AustriaKlosterneuburgAustria
| | - Emmanuel D. Dixon
- Hans Popper Laboratory of Molecular HepatologyDivision of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Sigurd F. Lax
- Department of PathologyHospital Graz IIAcademic Teaching Hospital of the Medical University of GrazGrazAustria,School of MedicineJohannes Kepler UniversityLinzAustria
| | - Michael Trauner
- Hans Popper Laboratory of Molecular HepatologyDivision of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria,Medical Intensive Care Unit 13H1. Division of Gastroenterology and HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
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21
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Nardo AD, Schneeweiss-Gleixner M, Bakail M, Dixon ED, Lax SF, Trauner M. Pathophysiological mechanisms of liver injury in COVID-19. LIVER INTERNATIONAL : OFFICIAL JOURNAL OF THE INTERNATIONAL ASSOCIATION FOR THE STUDY OF THE LIVER 2020. [PMID: 33190346 DOI: 10.1111/liv.14730.] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
The recent outbreak of coronavirus disease 2019 (COVID-19), caused by the Severe Acute Respiratory Syndrome Coronavirus-2 (SARS-CoV-2) has resulted in a world-wide pandemic. Disseminated lung injury with the development of acute respiratory distress syndrome (ARDS) is the main cause of mortality in COVID-19. Although liver failure does not seem to occur in the absence of pre-existing liver disease, hepatic involvement in COVID-19 may correlate with overall disease severity and serve as a prognostic factor for the development of ARDS. The spectrum of liver injury in COVID-19 may range from direct infection by SARS-CoV-2, indirect involvement by systemic inflammation, hypoxic changes, iatrogenic causes such as drugs and ventilation to exacerbation of underlying liver disease. This concise review discusses the potential pathophysiological mechanisms for SARS-CoV-2 hepatic tropism as well as acute and possibly long-term liver injury in COVID-19.
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Affiliation(s)
- Alexander D Nardo
- Hans Popper Laboratory of Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mathias Schneeweiss-Gleixner
- Medical Intensive Care Unit 13H1. Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - May Bakail
- Campus IT, Institute of Science and Technology Austria, Klosterneuburg, Austria
| | - Emmanuel D Dixon
- Hans Popper Laboratory of Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Sigurd F Lax
- Department of Pathology, Hospital Graz II, Academic Teaching Hospital of the Medical University of Graz, Graz, Austria.,School of Medicine, Johannes Kepler University, Linz, Austria
| | - Michael Trauner
- Hans Popper Laboratory of Molecular Hepatology, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Medical Intensive Care Unit 13H1. Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
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22
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Huimin S, Jing W, Chang HU, Chang L, Jianguo LI. [Effects of cholestasis and hypoxic hepatitis on prognosis of ICU patients: a retrospective study based on MIMIC Ⅲ database]. NAN FANG YI KE DA XUE XUE BAO = JOURNAL OF SOUTHERN MEDICAL UNIVERSITY 2020; 40:771-777. [PMID: 32895209 DOI: 10.12122/j.issn.1673-4254.2020.06.01] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
OBJECTIVE Abnormalities of liver-related indices are common in ICU patients, but the effects of cholestasis and hypoxic hepatitis in critically ill patients remains unclarified. The purpose of this study was to investigate the effects of cholestasis and hypoxic liver dysfunction on the prognosis of ICU patients. METHODS A retrospective study was conducted based on the data of patients admitted to the ICU for the first time between 2001 and 2011 archived in the MIMIC-Ⅲ database. The patients were divided into cholestasis, hypoxic hepatitis and control groups, and their 28-day case fatality rate as the primary outcome was compared among the groups. RESULTS A total of 5852 ICU patients were included in the analysis. The incidence of cholestasis and hypoxic liver dysfunction was 31.9% (1869/5852) and 17.9% (1046/5852), respectively. There was no significant difference in 28-day case fatality rate between cholestasis group and the control group. Compared with the control group, the patients with hypoxic hepatitis had a significantly higher 28-day case fatality rate (46% vs 35%, P < 0.01), a higher hospital case fatality rate (40% vs 31%, P < 0.01), and a higher ICU case fatality rate (35.7% vs 22.2%, P < 0.01). Logistic regression analysis showed that lactic acid (LAC), aspartate transaminase (AST), and international standard ratio (INR) were independent risk factors for 28-day case fatality rate. CONCLUSIONS The incidence of cholestatic liver dysfunction is higher than that of hypoxic hepatitis, but it does not increase the 28-day case fatality rate of the ICU patients, suggesting that cholestatic liver dysfunction may be the early adaptation of the liver to critical diseases.
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Affiliation(s)
- Song Huimin
- Zhongnan Hospital of Wuhan University, Wuhan, 430000 China
| | - Wang Jing
- Zhongnan Hospital of Wuhan University, Wuhan, 430000 China
| | - H U Chang
- Zhongnan Hospital of Wuhan University, Wuhan, 430000 China
| | - Liu Chang
- Zhongnan Hospital of Wuhan University, Wuhan, 430000 China
| | - L I Jianguo
- Zhongnan Hospital of Wuhan University, Wuhan, 430000 China
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23
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Mogahed EA, Ghita H, El-Raziky MS, El-Sherbini SA, Meshref D, El-Karaksy H. Secondary hepatic dysfunction in pediatric intensive care unit: Risk factors and outcome. Dig Liver Dis 2020; 52:889-894. [PMID: 32527656 DOI: 10.1016/j.dld.2020.04.035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Revised: 04/15/2020] [Accepted: 04/30/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Hepatic dysfunction has a significant role in intensive care unit patients' morbidity and mortality. AIM To study the frequency, risk factors and outcome of secondary hepatic dysfunction in children admitted to the pediatric intensive care unit. METHODS Secondary hepatic dysfunction was defined as the development of abnormal liver functions in a patient without a previous liver disease during intensive care unit stay. The following data were collected: age, gender, indication of admission, type of organ dysfunction, presence of sepsis, shock, need for inotropic support or mechanical ventilation, administered medications and mortality scores. Liver function tests were done on admission and at 7-day intervals. RESULTS One hundred and fifty-one patients were included. Forty-three (28.5%) acquired secondary hepatic dysfunction. Several risk factors were significantly associated with secondary hepatic dysfunction: sepsis (p<0.001), cardiovascular events (p<0.001), hypoxia (p<0.001), number of administered antibiotics (P = 0.001), use of inotropes (p<0.001) and mechanical ventilation (p = 0.001). Secondary hepatic dysfunction was significantly associated with mortality and prolonged length of stay (P=<0.001). CONCLUSION Secondary hepatic dysfunction is a common finding in the pediatric intensive care unit. Sepsis, cardiovascular events and hypoxia, are the main risk factors for secondary hepatic dysfunction. Mortality and prolonged length of stay are strongly related to secondary hepatic dysfunction.
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Affiliation(s)
- Engy A Mogahed
- Department of Pediatrics, Kasr Alainy Medical School, Cairo University, Cairo, Egypt.
| | - Haytham Ghita
- Department of Pediatrics, Kasr Alainy Medical School, Cairo University, Cairo, Egypt
| | - Mona S El-Raziky
- Department of Pediatrics, Kasr Alainy Medical School, Cairo University, Cairo, Egypt
| | - Seham A El-Sherbini
- Department of Pediatrics, Kasr Alainy Medical School, Cairo University, Cairo, Egypt
| | - Doaa Meshref
- Department of Pediatrics, Kasr Alainy Medical School, Cairo University, Cairo, Egypt
| | - Hanaa El-Karaksy
- Department of Pediatrics, Kasr Alainy Medical School, Cairo University, Cairo, Egypt
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24
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Liu L, Li X, Huang C, Bian Y, Liu X, Cao J, Qu W, Miao L. Bile acids, lipid and purine metabolism involved in hepatotoxicity of first-line anti-tuberculosis drugs. Expert Opin Drug Metab Toxicol 2020; 16:527-537. [PMID: 32436768 DOI: 10.1080/17425255.2020.1758060] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
OBJECTIVES Rifampin (RIF), isoniazid (INH) and pyrazinamide (PZA) are essential components of the short-term first-line anti-tuberculosis (anti-TB) chemotherapy regimen and can cause hepatotoxicity. However, the mechanism of anti-TB drug-induced hepatotoxicity (ATDH) is currently unclear. We investigate the relevant contributions to liver injury and the pathway of the above-mentioned drugs administered alone or in combination. METHODS UPLC-Q-TOF/MS-based metabolomics, bile acids (BAs) analysis and FXR/SHP detection were used to evaluate the toxicity of these drugs and clarify the underlying metabolism-related pathway. RESULTS In C57BL/6 mice administered the corrected clinical doses, RIF, INH and PZA could induced hepatotoxicity; with less toxicity in the combination therapy than RIF. The pathological biochemistry, BAs concentration and metabolically regulated FXR/SHP gene expression analyzes in mice were consistent with the metabolomics results. FXR played a role in the hepatotoxicity of anti-tuberculosis drugs in the obeticholic acid treated and FXR-/- mice. Additionally, the purine and lipid metabolic pathways were involved in ATDH. CONCLUSION ATDH was involved in bile acids and lipid and purine metabolism. The BAs metabolic pathway involvement in mice was validated in TB patients. The noninvasive metabolomics approach is more systemic than routine toxicity evaluation and can be used to assess compound toxicity and the underlying mechanism.
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Affiliation(s)
- Linsheng Liu
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University , Suzhou, China
| | - Xianglian Li
- College of Pharmaceutical Science, Soochow University , Suzhou, China
| | - Chenrong Huang
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University , Suzhou, China
| | - Yicong Bian
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University , Suzhou, China
| | - Xiaoxue Liu
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University , Suzhou, China
| | - Jun Cao
- Department of pharmacy, The Affiliated Infectious Diseases Hospital of Soochow University (The Fifth People's Hospital of Suzhou) , Suzhou, China
| | - Wenhao Qu
- College of Pharmaceutical Science, Soochow University , Suzhou, China
| | - Liyan Miao
- Department of Clinical Pharmacology, The First Affiliated Hospital of Soochow University , Suzhou, China.,College of Pharmaceutical Science, Soochow University , Suzhou, China
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25
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Choi JS, Chung KS, Lee EH, Lee SH, Lee SH, Kim SY, Jung JY, Kang YA, Park MS, Kim YS, Chang J, Leem AY. The role of bilirubin to albumin ratio as a predictor for mortality in critically ill patients without existing liver or biliary tract disease. Acute Crit Care 2020; 35:24-30. [PMID: 32131578 PMCID: PMC7056960 DOI: 10.4266/acc.2019.00738] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2019] [Accepted: 01/30/2020] [Indexed: 12/14/2022] Open
Abstract
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.
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Affiliation(s)
- Ji Soo Choi
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Kyung Soo Chung
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Eun Hye Lee
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Su Hwan Lee
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Sang Hoon Lee
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ji Ye Jung
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Ae Kang
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Young Sam Kim
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Joon Chang
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Ah Young Leem
- Division of Pulmonology, Department of Internal Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
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26
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Martins P, Verdelho Machado M. Secondary Sclerosing Cholangitis in Critically Ill Patients: An Underdiagnosed Entity. GE PORTUGUESE JOURNAL OF GASTROENTEROLOGY 2020; 27:103-114. [PMID: 32266307 PMCID: PMC7113589 DOI: 10.1159/000501405] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/24/2019] [Revised: 06/07/2019] [Indexed: 12/12/2022]
Abstract
Secondary sclerosing cholangitis in critically ill patients (SSC-CIP) is a recently identified cholestatic liver disease occurring in patients without prior history of hepatobiliary disease, after receiving treatment in the intensive care unit (ICU) in different settings, including cardiothoracic surgery, infection, trauma, and burns. It is a rare entity, being estimated to occur in 1/2,000 patients in an ICU; however, it is a dismal condition, with up to half of the patients dying during the ICU stay and with rapid progression to liver cirrhosis over weeks to months. SSC-CIP should be considered in the differential diagnosis of cholestasis in the ICU, particularly when cholestasis persists after recovery from the critical event. Diagnosis is established with magnetic resonance cholangiopancreatography or endoscopic retrograde cholangiopancreatography showing dilations and stenoses of the intrahepatic bile ducts as well as biliary casts. No available treatment has been shown to slow the rapid progression of the disease, and liver transplant referral should be considered early after the diagnosis of SSC-CIP. Increased awareness and timely diagnosis are crucial in order to improve the current appalling outcome.
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Affiliation(s)
- Pedro Martins
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
| | - Mariana Verdelho Machado
- Clínica Universitária de Gastrenterologia, Faculdade de Medicina, Universidade de Lisboa, Lisbon, Portugal
- Serviço de Gastrenterologia, Hospital de Santa Maria, CHULN, Lisbon, Portugal
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27
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Kaestner F, Seiler F, Rapp D, Eckert E, Müller J, Metz C, Bals R, Drexler H, Lepper PM, Göen T. Exposure of patients to di(2-ethylhexy)phthalate (DEHP) and its metabolite MEHP during extracorporeal membrane oxygenation (ECMO) therapy. PLoS One 2020; 15:e0224931. [PMID: 31999712 PMCID: PMC6992201 DOI: 10.1371/journal.pone.0224931] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2019] [Accepted: 10/24/2019] [Indexed: 01/13/2023] Open
Abstract
The plasticizer di(2-ethylhexyl)phthalate (DEHP) is often used for PVC medical devices, that are also largely used for intensive care medical treatments, like extracorporeal membrane oxygenation (ECMO) therapy. Due to the toxicological potential of DEHP, the inner exposure of patients with this plasticizer is a strong matter of concern as many studies have shown a high leaching potential of DEHP into blood. In this study, the inner DEHP exposure of patients undergoing ECMO treatment was investigated. The determined DEHP blood levels of ECMO patients and the patients of the control group ranged from 31.5 to 1009 μg/L (median 156.0 μg/L) and from 19.4 to 75.3 μg/L (median 36.4 μg/L), respectively. MEHP blood levels were determined to range from < LOD to 475 μg/L (median 15.9 μg/L) in ECMO patients and from < LOD to 9.9 μg/L (median 3.7 μg/L) in the control group patients, respectively. Increased DEHP exposure was associated with the number of cannulas and membranes of the ECMO setting, whereas residual diuresis decreased the exposure. Due to the suspected toxicological potential of DEHP, its use in medical devices should be further investigated, in particular for ICU patients with long-term exposure to PVC, like in ECMO therapy.
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Affiliation(s)
- Franziska Kaestner
- Department of Internal Medicine V, University Hospital of Saarland, Homburg, Germany
| | - Frederik Seiler
- Department of Internal Medicine V, University Hospital of Saarland, Homburg, Germany
| | - Daniel Rapp
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University, Homburg/Saar, Germany
| | - Elisabeth Eckert
- Institute and Outpatient Clinic of Occupational, Social and Environmental Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Johannes Müller
- Institute and Outpatient Clinic of Occupational, Social and Environmental Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Carlos Metz
- Department of Internal Medicine V, University Hospital of Saarland, Homburg, Germany
| | - Robert Bals
- Department of Internal Medicine V, University Hospital of Saarland, Homburg, Germany
| | - Hans Drexler
- Institute and Outpatient Clinic of Occupational, Social and Environmental Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Philipp M. Lepper
- Department of Internal Medicine V, University Hospital of Saarland, Homburg, Germany
| | - Thomas Göen
- Institute and Outpatient Clinic of Occupational, Social and Environmental Medicine, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
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28
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Horvatits T, Drolz A, Trauner M, Fuhrmann V. Liver Injury and Failure in Critical Illness. Hepatology 2019; 70:2204-2215. [PMID: 31215660 DOI: 10.1002/hep.30824] [Citation(s) in RCA: 77] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2018] [Accepted: 06/06/2019] [Indexed: 12/12/2022]
Abstract
The frequency of acquired liver injury and failure in critical illness has been significantly increasing over recent decades. Currently, liver injury and failure are observed in up to 20% of patients in intensive care units and are associated with significantly increased morbidity and mortality. Secondary forms of liver injury in critical illness are divided primarily into cholestatic, hypoxic, or mixed forms. Therefore, sufficient knowledge of underlying alterations (e.g., hemodynamic, inflammatory, or drug induced) is key to a better understanding of clinical manifestations, prognostic implications, as well as diagnostic and therapeutic options of acquired liver injury and failure. This review provides a structured approach for the evaluation and treatment of acquired liver injury and failure in critically ill patients.
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Affiliation(s)
- Thomas Horvatits
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Division of Gastroenterology & Hepatology, Department Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Andreas Drolz
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Division of Gastroenterology & Hepatology, Department Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology & Hepatology, Department Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.,Division of Gastroenterology & Hepatology, Department Internal Medicine 3, Medical University of Vienna, Vienna, Austria.,Department of Medicine B, Gastroenterology and Hepatology, University Münster, Münster, Germany
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29
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Gottlieb A, Canbay A. Why Bile Acids Are So Important in Non-Alcoholic Fatty Liver Disease (NAFLD) Progression. Cells 2019; 8:cells8111358. [PMID: 31671697 PMCID: PMC6912605 DOI: 10.3390/cells8111358] [Citation(s) in RCA: 83] [Impact Index Per Article: 16.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 10/27/2019] [Accepted: 10/28/2019] [Indexed: 02/07/2023] Open
Abstract
Non-alcoholic fatty liver disease (NAFLD) is a complex disease, affecting not just the liver, but also all other organs in the body. Despite an increasing amount of people worldwide developing NAFLD and having it progress to non-alcoholic steatohepatitis (NASH) and potentially cirrhosis, there is still no approved therapy. Therefore, huge efforts are being made to find and develop a successful treatment. One of the special interests is understanding the liver-gut axis and especially the role of bile acids in the progression of NAFLD. Farnesoid X receptor (FXR)-agonists have been approved und used in other liver diseases, such as primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC), and have shown signs of being able to decrease inflammation and potentially steatosis. This review will mainly focus on targets/ligands that play an important role in bile acid metabolism and give an overview of ongoing clinical as well as pre-clinical trials. With the complexity of the issue, we did not aim at giving a complete review, rather highlighting important targets and potential treatments that could be approved for NAFLD/NASH treatment within the next few years.
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Affiliation(s)
- Aline Gottlieb
- Department of Physiology, Johns Hopkins University, Baltimore, MD 21224, USA.
| | - Ali Canbay
- Department of Medicine, Ruhr University Bochum, University Hospital Knappschaftskrankenhaus Bochum, 44892 Bochum, Germany.
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30
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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. Int J Artif Organs 2019; 42:263-268. [DOI: 10.1177/0391398819834012] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
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.
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31
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Prevalence and Prognostic Value of Abnormal Liver Test Results in Critically Ill Children and the Impact of Delaying Parenteral Nutrition. Pediatr Crit Care Med 2018; 19:1120-1129. [PMID: 30234740 PMCID: PMC6282934 DOI: 10.1097/pcc.0000000000001734] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In the Early versus Late Parenteral Nutrition in the Pediatric ICU randomized controlled trial, delaying parenteral nutrition to beyond day 7 (late parenteral nutrition) was clinically superior to supplemental parenteral nutrition initiated within 24 hours (early parenteral nutrition), but resulted in a higher rise in bilirubin. We aimed to document prevalence and prognostic value of abnormal liver tests in the PICU and the impact hereon of withholding early parenteral nutrition. DESIGN Preplanned secondary analysis of the Early versus Late Parenteral Nutrition in the Pediatric ICU randomized controlled trial. Total bilirubin, alanine aminotransferase, aspartate aminotransferase, gamma-glutamyl transpeptidase, alkaline phosphatase plasma concentrations were measured systematically in PICU. Liver test analyses were adjusted for baseline characteristics including severity of illness. SETTING Three PICUs in Belgium, the Netherlands, and Canada. PATIENTS As neonatal jaundice was considered a confounder, only the 1,231 of the 1,440 Early versus Late Parenteral Nutrition in the Pediatric ICU-patients 28 days to 17 years old were included. INTERVENTIONS Late parenteral nutrition as compared with early parenteral nutrition. MEASUREMENTS AND MAIN RESULTS During the first seven PICU days, the prevalence of cholestasis (> 2 mg/dL [34.2 μmol/L] bilirubin) ranged between 3.8% and 4.9% and of hypoxic hepatitis (≥ 20-fold upper limit of normality for alanine aminotransferase and aspartate aminotransferase) between 0.8% and 2.2%, both unaffected by the use of parenteral nutrition. Throughout the first week in PICU plasma bilirubin concentrations were higher in late parenteral nutrition patients (p < 0.05), but became comparable to early parenteral nutrition patients as soon as parenteral nutrition was started on day 8. Plasma concentrations of gamma-glutamyl transpeptidase, alkaline phosphatase, alanine aminotransferase, and aspartate aminotransferase were unaffected by parenteral nutrition. High day 1 plasma concentrations of gamma-glutamyl transpeptidase, alanine aminotransferase, and aspartate aminotransferase (p ≤ 0.01), but not alkaline phosphatase, were independent risk factors for PICU mortality. Day 1 plasma bilirubin concentrations displayed a U-shaped association with PICU mortality, with higher mortality associated with bilirubin less than 0.20 mg/dL and greater than 0.76 mg/dL (< 3.42 μmol/L and > 13 μmol/L) (p ≤ 0.01). CONCLUSIONS Overt cholestasis and hypoxic hepatitis were rare and unrelated to the nutritional strategy. However, withholding parenteral nutrition up to 1 week in PICU increased plasma bilirubin. A mild elevation of bilirubin on the first PICU day was associated with lower risk of death and may reflect a stress response, rather than true cholestasis.
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32
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[Acute liver failure]. ACTA ACUST UNITED AC 2018; 22:38-47. [PMID: 32288865 PMCID: PMC7138136 DOI: 10.1007/s00740-018-0243-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/02/2022]
Abstract
Acute liver failure (ALF) is a rare condition with fatal outcome. Characteristic is rapid onset of liver damage without preexisting liver diseases, including hepatic encephalopathy and coagulopathy. Early and correct diagnosis is essential for further management of patients, since diagnosis impacts therapy choice. Survival of patients with ALF has improved dramatically due to advances in critical care medicine and the use of liver transplantation.
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Tunney R, Scott J, Rudralingam V, Liong S, Athwal VS. Secondary sclerosing cholangitis following extracorporeal membrane oxygenation for acute respiratory distress in polytrauma. Clin Case Rep 2018; 6:1849-1853. [PMID: 30214777 PMCID: PMC6132136 DOI: 10.1002/ccr3.1660] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2017] [Revised: 02/23/2018] [Accepted: 04/18/2018] [Indexed: 11/10/2022] Open
Abstract
Secondary sclerosing cholangitis is a recently identified phenomenon affecting the biliary tree. A subtype has been described in critically ill patients (SSC-CIP). However, underlying mechanisms are unknown, and few cases have been reported following extracorporeal membrane oxygenation (ECMO). We present a 19-year-old male with SSC-CIP after ECMO following major trauma.
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Affiliation(s)
- Ruth Tunney
- Wythenshawe HospitalManchester University Hospitals NHS Foundation TrustManchesterUK
| | - Jennifer Scott
- Wythenshawe HospitalManchester University Hospitals NHS Foundation TrustManchesterUK
- Divsion of Diabetes, Endocrine and GastroenterologyFaculty of Biology, Medicine & HealthUniversity of ManchesterManchesterUK
| | - Velauthan Rudralingam
- Wythenshawe HospitalManchester University Hospitals NHS Foundation TrustManchesterUK
| | - Sue Liong
- Wythenshawe HospitalManchester University Hospitals NHS Foundation TrustManchesterUK
| | - Varinder S. Athwal
- Wythenshawe HospitalManchester University Hospitals NHS Foundation TrustManchesterUK
- Divsion of Diabetes, Endocrine and GastroenterologyFaculty of Biology, Medicine & HealthUniversity of ManchesterManchesterUK
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Scarpati G, De Robertis E, Esposito C, Piazza O. Hepatic encephalopathy and cirrhotic cardiomyopathy in Intensive Care Unit. Minerva Anestesiol 2018; 84:970-979. [DOI: 10.23736/s0375-9393.18.12343-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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35
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Yu Q, Jiang Z, Zhang L. Bile acid regulation: A novel therapeutic strategy in non-alcoholic fatty liver disease. Pharmacol Ther 2018; 190:81-90. [PMID: 29684468 DOI: 10.1016/j.pharmthera.2018.04.005] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Non-alcoholic fatty liver disease (NAFLD) is characterized by excessive fat deposition in the liver in the absence of significant alcohol consumption. Dysregulated bile acid (BA) metabolism is an important indicator in the pathology of NAFLD, which could progress into more severe forms of liver injury. Lipid metabolism, immune environment and intestinal bacteria are all affected by dysregulated BA metabolism directly, but the mechanisms remain unclear. Several drug candidates that target BA metabolism, either used alone or in combination with other agents, are currently under development for treatment of NAFLD. Here, we summarize the relationship of dysregulated BA metabolism and NAFLD, discuss the effects and mechanisms of dysregulated BAs-induced lipid metabolism disorder. Challenges in developing novel treatments are also discussed.
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Affiliation(s)
- Qinwei Yu
- Jiangsu Key Laboratory of Drug Screening, China Pharmaceutical University, Nanjing 210009, China
| | - Zhenzhou Jiang
- Jiangsu Key Laboratory of Drug Screening, China Pharmaceutical University, Nanjing 210009, China.
| | - Luyong Zhang
- Jiangsu Key Laboratory of Drug Screening, China Pharmaceutical University, Nanjing 210009, China; Center for Drug Screening and Pharmacodynamics Evaluation, School of Pharmacy, Guangdong Pharmaceutical University, Guangzhou 510006, China.
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Loeser K, Seemann S, König S, Lenhardt I, Abdel-Tawab M, Koeberle A, Werz O, Lupp A. Protective Effect of Casperome ®, an Orally Bioavailable Frankincense Extract, on Lipopolysaccharide- Induced Systemic Inflammation in Mice. Front Pharmacol 2018; 9:387. [PMID: 29731716 PMCID: PMC5921439 DOI: 10.3389/fphar.2018.00387] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Accepted: 04/04/2018] [Indexed: 12/12/2022] Open
Abstract
Introduction: Despite recent advances in critical care, sepsis remains a crucial cause of morbidity and mortality in intensive care units. Therefore, the identification of new therapeutic strategies is of great importance. Since ancient times, frankincense is used in traditional medicine for the treatment of chronic inflammatory disorders such as rheumatoid arthritis. Thus, the present study intends to evaluate if Casperome® (Casp), an orally bioavailable soy lecithin-based formulation of standardized frankincense extract, is able to ameliorate systemic effects and organ damages induced by severe systemic inflammation using a murine model of sepsis, i.e., intraperitoneal administration of lipopolysaccharides (LPS). Methods: Male 60-day-old mice were assigned to six treatment groups: (1) control, (2) LPS, (3) soy lecithin (blank lecithin without frankincense extract), (4) Casp, (5) soy lecithin plus LPS, or (6) Casp plus LPS. Soy lecithin and Casp were given 3 h prior to LPS treatment; 24 h after LPS administration, animals were sacrificed and health status and serum cytokine levels were evaluated. Additionally, parameters representing liver damage or liver function and indicating oxidative stress in different organs were determined. Furthermore, markers for apoptosis and immune cell redistribution were assessed by immunohistochemistry in liver and spleen. Results: LPS treatment caused a decrease in body temperature, blood glucose levels, liver glycogen content, and biotransformation capacity along with an increase in serum cytokine levels and oxidative stress in various organs. Additionally, apoptotic processes were increased in spleen besides a pronounced immune cell infiltration in both liver and spleen. Pretreatment with Casp significantly improved health status, blood glucose values, and body temperature of the animals, while serum levels of pro-inflammatory cytokines and oxidative stress in all organs tested were significantly diminished. Finally, apoptotic processes in spleen, liver glycogen loss, and immune cell infiltration in liver and spleen were distinctly reduced. Casp also appears to induce various cytochromeP450 isoforms, thus causing re-establishment of liver biotransformation capacity in LPS-treated mice. Conclusion: Casp displayed anti-inflammatory, anti-oxidative, and hepatoprotective effects. Thus, orally bioavailable frankincense extracts may serve as a new supportive treatment option in acute systemic inflammation and accompanied liver dysfunction.
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Affiliation(s)
- Konstantin Loeser
- Institute of Pharmacology and Toxicology, Jena University Hospital, Jena, Germany.,Chair of Pharmaceutical Medicinal Chemistry, Institute of Pharmacy, Friedrich Schiller University Jena, Jena, Germany
| | - Semjon Seemann
- Institute of Pharmacology and Toxicology, Jena University Hospital, Jena, Germany
| | - Stefanie König
- Chair of Pharmaceutical Medicinal Chemistry, Institute of Pharmacy, Friedrich Schiller University Jena, Jena, Germany
| | - Isabell Lenhardt
- Institute of Pharmacology and Toxicology, Jena University Hospital, Jena, Germany
| | | | - Andreas Koeberle
- Chair of Pharmaceutical Medicinal Chemistry, Institute of Pharmacy, Friedrich Schiller University Jena, Jena, Germany
| | - Oliver Werz
- Chair of Pharmaceutical Medicinal Chemistry, Institute of Pharmacy, Friedrich Schiller University Jena, Jena, Germany
| | - Amelie Lupp
- Institute of Pharmacology and Toxicology, Jena University Hospital, Jena, Germany
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Lee SH, Park MS, Lee JG, Song JH, Chung KS, Jung JY, Kim EY, Kim YS, Kim SK, Chang J, Paik HC, Kim SY. Rare causes of hyperbilirubinemia after lung transplantation: our experience at a single center. J Thorac Dis 2017; 9:5030-5039. [PMID: 29312707 DOI: 10.21037/jtd.2017.11.118] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Lung transplantation is the last treatment option for end-stage lung disease, and the number of lung transplantations has been steadily increasing. Hyperbilirubinemia is a rare complication after lung transplantation. The aim of this study was to review rare causes of hyperbilirubinemia after lung transplantation at our center. Methods In this single-center study, we retrospectively reviewed the records of 116 consecutive lung transplantation patients who underwent lung transplantation at Severance Hospital and Gangnam Severance Hospital of Yonsei University College of Medicine in South Korea between December 22, 2010 and January 1, 2016. Hyperbilirubinemia was defined as a total bilirubin level exceeding 5 mg/dL for at least 3 days after lung transplantation. Results Hyperbilirubinemia occurred in 33 patients (28.4%) who received lung transplants at our institution. Twenty-four cases involved common causes such as drug toxicity, biliary tract stone, sepsis, and bleeding. However, rare causes of hyperbilirubinemia including hemophagocytic lymphohistiocytosis (HLH), thrombotic microangiopathy (TMA), and ischemic cholangiopathy were observed in 9 (7.8%) patients during the study period. All patients with hyperbilirubinemia due to a rare cause died despite aggressive treatment. Conclusion Causes of hyperbilirubinemia after lung transplantation are varied, and the prognosis of patients with hyperbilirubinemia arising from rare causes was poor. Therefore, early evaluation and management of hyperbilirubinemia after lung transplantation is important to improve patient outcomes.
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Affiliation(s)
- Su Hwan Lee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Ewha Womans University, Seoul, Republic of Korea.,Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Moo Suk Park
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Jin Gu Lee
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joo Han Song
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Kyung Soo Chung
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Ji Ye Jung
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Eun Young Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Young Sam Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Se Kyu Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Joon Chang
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Hyo Chae Paik
- Department of Thoracic and Cardiovascular Surgery, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
| | - Song Yee Kim
- Division of Pulmonology, Department of Internal Medicine, Institute of Chest Diseases, Severance Hospital, Yonsei University College of Medicine, Seoul, Republic of Korea
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Cholestatic Alterations in the Critically Ill: Some New Light on an Old Problem. Chest 2017; 153:733-743. [PMID: 28847548 DOI: 10.1016/j.chest.2017.08.018] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2017] [Revised: 07/10/2017] [Accepted: 08/14/2017] [Indexed: 12/12/2022] Open
Abstract
Liver dysfunction and jaundice are traditionally viewed as late features of sepsis and other critical illnesses and are associated with a complicated ICU stay. However, study results suggest that cholestatic alterations occur early in the course of critical illnesses, perceived only as minor abnormalities in routinely used biochemical liver tests. Inflammation-induced alterations in the transport of bile acids (BAs) appear to drive BAs and bilirubin toward the systemic circulation. Ongoing BA synthesis with an, at least partial, loss of feedback inhibition further contributes to elevated circulating BAs and bilirubin. To what extent these changes reflect a biochemical epiphenomenon, true illness-induced liver dysfunction, or a beneficial and adaptive response to illness should be investigated further. Because of the lack of specificity of standard laboratory tests, especially in the context of a complex systemic condition such as critical illness, identifying true cholestatic liver dysfunction remains a great challenge. However, high levels of cholestatic markers that are sustained in patients with prolonged critical illness almost always indicate a complicated illness course and should be monitored closely. Preventing cholestatic liver dysfunction comprises minimizing inflammation and hypoxia in the liver and preventing hyperglycemia, avoiding early use of parenteral nutrition, and reducing the administration of avoidable drugs. Future research on the effects of BAs and on modulating underlying drivers of cholestasis induced by critical illness is warranted as this could open perspectives for a targeted diagnostic approach and ultimately for novel therapies to improve outcome.
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Chang PE, Goh BBG, Ekstrom V, Ong ML, Tan CK. Low serum albumin predicts early mortality in patients with severe hypoxic hepatitis. World J Hepatol 2017; 9:959-966. [PMID: 28839516 PMCID: PMC5550761 DOI: 10.4254/wjh.v9.i22.959] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2017] [Revised: 03/24/2017] [Accepted: 06/13/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To evaluate the incidence, etiology, and predictors of mortality of severe hypoxic hepatitis.
METHODS We used computerized patient records to identify consecutive cases of severe hypoxic hepatitis admitted to a tertiary hospital in Singapore over a one-year period. We defined severe hypoxic hepatitis as elevation of serum transaminases more than 100 times upper limit of normal in the clinical setting of cardiac, circulatory or respiratory failure after exclusion of other causes of hepatitis. We used multivariable regression analysis to determine predictors for mortality.
RESULTS We identified 75 cases of severe hypoxic hepatitis out of 71380 hospital admissions over one year, providing an incidence of 1.05 cases per 1000 admissions. Median age was 65 years (range 19-88); 57.3% males. The most common etiologies of severe hypoxic hepatitis were acute myocardial infarction and sepsis. Fifty-three patients (71%) died during the hospitalization. The sole independent predictive factor for mortality was serum albumin measured at the onset of severe hypoxic hepatitis. Patients with low serum albumin of less than 28 g/L have more than five-fold increase risk of death (OR = 5.39, 95%CI: 1.85-15.71).
CONCLUSION Severe hypoxic hepatitis is uncommon but has a high mortality rate. Patients with low serum albumin are at highest risk of death.
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Al-Chalabi A, Matevossian E, von Thaden A, Schreiber C, Radermacher P, Huber W, Perez Ruiz de Garibay A, Kreymann B. Evaluation of an ADVanced Organ Support (ADVOS) system in a two-hit porcine model of liver failure plus endotoxemia. Intensive Care Med Exp 2017; 5:31. [PMID: 28677045 PMCID: PMC5496922 DOI: 10.1186/s40635-017-0144-3] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2016] [Accepted: 06/07/2017] [Indexed: 12/11/2022] Open
Abstract
Background Novel extracorporeal procedures are constantly being developed and evaluated for use in patients with sepsis. Preclinical evaluation of such procedures usually requires testing in large animal models. In the present work, the safety and efficacy of a recently developed ADVanced Organ Support (ADVOS) system in a newly developed large animal two-hit model of liver failure combined with endotoxemia were tested. Methods After establishing the model in more than 50 animals, a randomized study was performed. An inflammatory cholestatic liver injury was initially provoked in pigs. Three days after surgery, endotoxin was gradually administered during 7½ h. Animals were randomized to receive standard medical treatment either with (ADVOS group, n = 5) or without ADVOS (control group, n = 5). The ADVOS treatment was started 2½ h after endotoxemia and continued for 7 h. Survival, cardiovascular, respiratory, renal, liver, coagulation, and cerebral parameters were analyzed. Results Three days after surgery, cholestatic injury resulted in hyperbilirubinemia [5.0 mg/dl (IQR 4.3–5.9 mg/dl)], hyperammonemia [292 μg/dl (IQR 291–296 μg/dl)], leukocytosis [20.2 103/μl (IQR 17.7–21.8 103/μl)], and hyperfibrinogenemia [713 mg/dl (IQR 654–803 mg/dl)]. After endotoxemia, the ADVOS procedure stabilized cardiovascular, respiratory, and renal parameters and eliminated surrogate markers as bilirubin [2.3 (IQR 2.3–3.0) vs. 5.5 (IQR 4.6–5.6) mg/dl, p = 0.001] and creatinine [1.4 (IQR 1.1–1.7) vs. 2.3 (IQR 2.1–3.1) mg/dl, p = 0.01]. Mortality: All animals in the ADVOS group survived, while all animals in the control group expired during the 10-h observation period (p = 0.002). No adverse events related to the procedure were observed. Conclusions The ADVOS procedure showed a promising safety and efficacy profile and improved survival in a sepsis-like animal model with dysfunction of multiple organs. An amelioration of major organ functions (heart and lung) combined with removal of markers for kidney and liver function was observed. Electronic supplementary material The online version of this article (doi:10.1186/s40635-017-0144-3) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Ahmed Al-Chalabi
- Jamaica Hospital Medical Center, Phase II Building, 8900 Van Wyck Expy Ste 2, Richmond Hill, New York City, NY, 11418, USA
| | - Edouard Matevossian
- Chirurgische Klinik und Poliklinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | - Anne von Thaden
- German Center for Neurodegenerative Diseases (DZNE) e.V., Lynen-Str. 17, 81377, Munich, Germany
| | - Catherine Schreiber
- Institute of Medical and Polymer Engineering, Department of Mechanical Engineering, Technische Universität München, Munich, Germany.,Hepa Wash GmbH, Agnes-Pockels-Bogen 1, 80992, Munich, Germany
| | - Peter Radermacher
- Institut für Anästhesiologische Pathophysiologie und Verfahrensentwicklung, Universitätsklinikum Ulm, Helmholtzstr. 8/1, 89081, Ulm, Germany
| | - Wolfgang Huber
- II Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany
| | | | - Bernhard Kreymann
- Hepa Wash GmbH, Agnes-Pockels-Bogen 1, 80992, Munich, Germany. .,II Medizinische Klinik, Klinikum rechts der Isar, Technische Universität München, Ismaninger Str. 22, 81675, Munich, Germany.
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Horvatits T, Drolz A, Rutter K, Roedl K, Langouche L, Van den Berghe G, Fauler G, Meyer B, Hülsmann M, Heinz G, Trauner M, Fuhrmann V. Circulating bile acids predict outcome in critically ill patients. Ann Intensive Care 2017; 7:48. [PMID: 28466463 PMCID: PMC5413465 DOI: 10.1186/s13613-017-0272-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 04/20/2017] [Indexed: 02/07/2023] Open
Abstract
Background Jaundice and cholestatic hepatic dysfunction are frequent findings in critically ill patients associated with increased mortality. Cholestasis in critically ill patients is closely associated with stimulation of pro-inflammatory cytokines resulting in impaired bile secretion and subsequent accumulation of bile acids. Aim of this study was to evaluate the clinical role of circulating bile acids in critically ill patients. Methods Total and individual serum bile acids were assessed via high-performance liquid chromatography in 320 critically ill patients and 19 controls. Results Total serum bile acids were threefold higher in septic than cardiogenic shock patients and sixfold higher than in post-surgical patients or controls (p < 0.001). Elevated bile acid levels correlated with severity of illness, renal dysfunction and inflammation (p < 0.05). Total bile acids predicted 28-day mortality independently of sex, age, serum bilirubin and severity of illness (HR 1.041, 95% CI 1.013–1.071, p < 0.005). Best prediction of mortality of total bile acids was seen in patients suffering from septic shock. Conclusions Individual and total BAs are elevated by various degrees in different shock conditions. BAs represent an early predictor of short-term survival in a mixed cohort of ICU patients and may serve as marker for early risk stratification in critically ill patients. Future studies should elucidate whether modulation of BA metabolism and signalling influences the clinical course and outcome in critically ill patients. Electronic supplementary material The online version of this article (doi:10.1186/s13613-017-0272-7) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Thomas Horvatits
- Division of Gastroenterology and Hepatology, Department Internal Medicine 3, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Andreas Drolz
- Division of Gastroenterology and Hepatology, Department Internal Medicine 3, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Karoline Rutter
- Division of Gastroenterology and Hepatology, Department Internal Medicine 3, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Kevin Roedl
- Division of Gastroenterology and Hepatology, Department Internal Medicine 3, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany
| | - Lies Langouche
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Louvain, Belgium
| | - Greet Van den Berghe
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, KU Leuven, Louvain, Belgium
| | - Günter Fauler
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Brigitte Meyer
- 5th Medical Department, Kaiser Franz Josef Spital - SMZ Süd, Vienna, Austria
| | - Martin Hülsmann
- Division of Cardiology, Department Internal Medicine 2, Medical University of Vienna, Vienna, Austria
| | - Gottfried Heinz
- Division of Cardiology, Department Internal Medicine 2, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department Internal Medicine 3, Medical University of Vienna, Vienna, Austria
| | - Valentin Fuhrmann
- Division of Gastroenterology and Hepatology, Department Internal Medicine 3, Medical University of Vienna, Vienna, Austria. .,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Germany.
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Schade I, Radakovic D, Hoffmann J, Sommer SP, Stefenelli U, Schimmer C, Leyh RG, Aleksic I. Secondary sclerosing cholangitis in cardiac surgical patients: A complication with a dismal prognosis. J Thorac Cardiovasc Surg 2017; 154:906-912. [PMID: 28554673 DOI: 10.1016/j.jtcvs.2017.04.041] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/14/2016] [Revised: 04/04/2017] [Accepted: 04/13/2017] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Secondary sclerosing cholangitis in critically ill patients is a rapidly progressing disease leading to biliary fibrosis and cirrhosis. We describe the course of sclerosing cholangitis in critically ill patients after cardiac surgery and compare this with matched patients. METHODS A retrospective search for "secondary sclerosing cholangitis" and "liver and/or hepatic failure" in all adult patients (aged 18-93 years) who underwent cardiac surgery from April 2007 to March 2016 identified 192 of 8625 patients. Of those, 12 were diagnosed with sclerosing cholangitis in critically ill patients (incidence, 0.14%). A 3:1 matching was performed. Laboratory values, pharmacologic requirements, ventilation times, mechanical circulatory support, and endoscopic retrograde cholangiopancreatography studies were extracted from the hospital database. RESULTS A total of 9 men and 3 women were affected (age 71 years; range, 59.8-75.5 years). Critically ill patients with sclerosing cholangitis required vasoconstrictors and inotropes longer than control patients (norepinephrine 356.5 hours [264.5-621] vs 68 hours [15-132.5], P = .003; enoximone 177 hours [124.3-249.5] vs 48.5 hours [12-81 hours], P < .001, respectively). Critically ill patients with sclerosing cholangitis had longer intubation time (628.5 hours [377.3-883] vs 25 hours [9.8-117.5]; P < .001) and more surgical revisions (3 [2.5-6] vs 1 [0-2], P = .003) than the matching group. Bilirubin (23.3 mg/dL [14.4-32.9] vs 1 mg/dL [0.6-2.7]; P < .001), gamma-glutamyltransferase (1082.3 U/L [259.5-2265.7] vs 53.8 U/L [35.1-146]; P < .001), and alkaline phosphatase (751.5 U/L [372-1722.3] vs 80.5 U/L [53.3-122]; P < .001) were higher in critically ill patients with sclerosing cholangitis. One critically ill patient with sclerosing cholangitis underwent successful liver transplantation. A total of 11 patients sclerosing cholangitis died (92%) versus 12 patients (33%, P < .001) in the control group. CONCLUSIONS Sclerosing cholangitis in critically ill patients is a fatal complication in patients undergoing cardiac surgery who have a complicated postoperative course with prolonged vasoconstrictor, inotropic, and respiratory therapy, or who require frequent surgical revisions. Liver transplantation remains the only curative option but is often precluded by the age and critical state of patients undergoing cardiac surgery.
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Affiliation(s)
- Ina Schade
- Department of Thoracic and Cardiovascular Surgery, Julius-Maximilians-University, Würzburg, Germany
| | - Dejan Radakovic
- Department of Thoracic and Cardiovascular Surgery, Julius-Maximilians-University, Würzburg, Germany
| | - Jörg Hoffmann
- Department of Thoracic and Cardiovascular Surgery, Julius-Maximilians-University, Würzburg, Germany
| | - Sebastian-Patrick Sommer
- Department of Thoracic and Cardiovascular Surgery, Julius-Maximilians-University, Würzburg, Germany
| | | | - Christoph Schimmer
- Department of Thoracic and Cardiovascular Surgery, Julius-Maximilians-University, Würzburg, Germany
| | - Rainer G Leyh
- Department of Thoracic and Cardiovascular Surgery, Julius-Maximilians-University, Würzburg, Germany
| | - Ivan Aleksic
- Department of Thoracic and Cardiovascular Surgery, Julius-Maximilians-University, Würzburg, Germany.
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Forsaken Foregut: Case Report of Simultaneous Black Esophagus and Ischemic Cholangiopathy. Case Rep Med 2017; 2017:8362613. [PMID: 28523071 PMCID: PMC5421083 DOI: 10.1155/2017/8362613] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2017] [Accepted: 04/11/2017] [Indexed: 01/13/2023] Open
Abstract
Black esophagus or acute esophageal necrosis rarely occurs after severe hemodynamic compromise or low-flow states. Other contributing factors may include corrosive injury from gastric contents and diminished mucosal repair mechanisms. Ischemic cholangitis, another rare clinical entity, is also usually the result of a significant vascular and/or hypotensive insult to the biliary tree. We describe the first case of combined acute esophageal necrosis and ischemic cholangiopathy in a 62-year-old male who completely recovered from the esophageal injury but developed progressive liver failure from ischemic cholangiopathy.
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Weemhoff JL, Woolbright BL, Jenkins RE, McGill MR, Sharpe MR, Olson JC, Antoine DJ, Curry SC, Jaeschke H. Plasma biomarkers to study mechanisms of liver injury in patients with hypoxic hepatitis. Liver Int 2017; 37:377-384. [PMID: 27429052 PMCID: PMC5243938 DOI: 10.1111/liv.13202] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 07/12/2016] [Indexed: 12/17/2022]
Abstract
BACKGROUND & AIMS Hypoxic hepatitis is a clinical condition precipitated by prolonged periods of oxygen deprivation to the liver. It can have several underlying causes. Despite its prevalence in critically ill patients, which can reach upwards of 10%, very little is known about the mechanisms of injury. Thus, we set out to measure previously identified circulating biomarkers in an attempt to describe mechanisms of injury following hypoxic hepatitis. METHODS Plasma from patients diagnosed with hypoxic hepatitis was collected for this study. Biomarkers of hepatocellular injury, mitochondrial damage and cell death were measured. These results were compared against results obtained from well-characterized acetaminophen overdose patients. RESULTS At peak injury, ALT measured 4082±606 U/L and gradually decreased over 5 days, corresponding to the clinically observed pattern of hypoxic hepatitis. Levels of GDH showed a similar pattern, but neither ALT nor GDH were significantly higher in these patients than in acetaminophen patients. Plasma levels of DNA fragments mimicked hepatocellular injury as measured by ALT and miRNA-122. Interestingly, we found a significant increase in caspase-cleaved cytokeratin-18; however, the full-length form greatly exceeded the cleaved form at the time of maximum injury (45837±12085 vs 2528±1074 U/L). We also found an increase in acHMGB1 at later time points indicating a possible role of inflammation, but cytokine levels at these times were actually decreased relative to early time points. CONCLUSIONS The mechanism of injury following hypoxic hepatitis involves mitochondrial damage and DNA fragmentation. Importantly, necrosis, rather than apoptosis, is the main mode of cell death.
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Affiliation(s)
- James L. Weemhoff
- Department of Pharmacology, Toxicology, and Therapeutics, University of Kansas Medical Center, Kansas City, KS USA
| | - Benjamin L. Woolbright
- Department of Pharmacology, Toxicology, and Therapeutics, University of Kansas Medical Center, Kansas City, KS USA
| | - Rosalind E. Jenkins
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool UK
| | - Mitchell R. McGill
- Department of Pharmacology, Toxicology, and Therapeutics, University of Kansas Medical Center, Kansas City, KS USA
| | - Matthew R. Sharpe
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS USA
| | - Jody C. Olson
- Department of Internal Medicine, University of Kansas Medical Center, Kansas City, KS USA
| | - Daniel J. Antoine
- MRC Centre for Drug Safety Science, Department of Molecular and Clinical Pharmacology, Institute of Translational Medicine, University of Liverpool, Liverpool UK
| | - Steven C. Curry
- Department of Medical Toxicology, Banner - University Medical Center Phoenix, Department of Medicine, and the Center for Toxicology and Pharmacology Education and Research, University of Arizona College of Medicine, Phoenix, Arizona
| | - Hartmut Jaeschke
- Department of Pharmacology, Toxicology, and Therapeutics, University of Kansas Medical Center, Kansas City, KS USA
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Abstract
BACKGROUND The liver has a number of functions in innate immunity. These functions predispose the liver to innate immune-mediated liver injury when inflammation goes unchecked. Significant progress has been made in the last 25 years on sterile inflammatory liver injury in a number of models; however, a great deal of controversy and many questions about the nature of sterile inflammation still exist. AIM The goal of this article is to review sterile inflammatory liver injury using both a basic approach to what constitutes the inflammatory injury, and through examination of current models of liver injury and inflammation. This information will be tied to human patient conditions when appropriate. RELEVANCE FOR PATIENTS Inflammation is one of the most critical factors for managing in-patient liver disease in a number of scenarios. More information is needed for both scientists and clinicians to develop rational treatments.
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Affiliation(s)
- Benjamin L Woolbright
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
| | - Hartmut Jaeschke
- Department of Pharmacology, Toxicology & Therapeutics, University of Kansas Medical Center, Kansas City, Kansas, USA
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46
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Horvatits T, Drolz A, Roedl K, Rutter K, Ferlitsch A, Fauler G, Trauner M, Fuhrmann V. Serum bile acids as marker for acute decompensation and acute-on-chronic liver failure in patients with non-cholestatic cirrhosis. Liver Int 2017; 37:224-231. [PMID: 27416294 DOI: 10.1111/liv.13201] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Accepted: 07/04/2016] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Retention of bile acids (BAs) plays a central role in hepatic damage and disturbed BA signalling in liver disease. However, there is lack of data regarding the association of BAs with clinical complications, acute decompensation (AD) and acute-on-chronic liver failure (ACLF). Thus, we aimed to evaluate the impact of circulating serum BAs for complications in patients with cirrhosis. METHODS One hundred and forty-three patients with cirrhosis were included in this prospective cohort-type observational study. Total serum BAs and individual BA composition were assessed in all patients on admission via high-performance liquid chromatography. Clinical complications with respect to AD, ACLF and 1-year transplant-free survival were recorded. RESULTS Total BAs and individual serum BAs were significantly higher in patients with bacterial infection, AD and ACLF (P<.001) and correlated significantly with model of end-stage liver disease (MELD) and hepatic venous pressure gradient (P<.001). Total BAs predicted new onset of AD or ACLF during follow-up (OR 1.025, 95% CI: 1.012-1.038, P<.001). Best cut-off predicting new onset of AD/ACLF and survival during course of time was total BAs ≥36.9 μmol/L. CONCLUSIONS Serum total and individual BAs are associated with AD and ACLF in patients with cirrhosis. Assessment of total BAs could serve as additional marker for risk stratification in cirrhotic patients with respect to new onset of AD and ACLF.
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Affiliation(s)
- Thomas Horvatits
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Drolz
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kevin Roedl
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Karoline Rutter
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Arnulf Ferlitsch
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Günter Fauler
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Michael Trauner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Valentin Fuhrmann
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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47
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Saloojee A, Skinner DL, Loots E, Hardcastle TC, Muckart DJJ. Hepatic dysfunction: A common occurrence in severely injured patients. Injury 2017; 48:127-132. [PMID: 27599394 DOI: 10.1016/j.injury.2016.08.017] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/20/2016] [Revised: 08/12/2016] [Accepted: 08/26/2016] [Indexed: 02/02/2023]
Abstract
BACKGROUND Hepatic dysfunction (HD) is a common finding in critically ill patients. The underlying pathophysiological process is one of either cholestasis or hypoxic liver injury (HLI). Using serum bilirubin, our study aimed to determine the incidence of HD in a critically ill trauma population, identify risk factors and analyse the impact on outcomes. METHODS A retrospective observational study was performed on all patients admitted to the Level 1 Trauma Unit ICU at Inkosi Albert Luthuli Central Hospital in Durban, South Africa (IALCH) from 01/01/2012 until 31/12/2012. HD was defined as a total bilirubin greater than 34.2μmol/l (2mg/dL). Additional demographic, physiological, biochemical, and pharmaceutical risk factors for hepatic dysfunction were identified and recorded. RESULTS Two hundred and twenty five patients were included in the study of whom 48 (21.3%) developed HD. An increased duration of ventilation (median 15days [inter-quartile range 6-19] vs 6days [IQR 3-11] p<0.001), prolonged length of stay (median 19days [IQR 8.5-31] vs 7days [IQR 3-13] p<0.001), and higher mortality rate (31.3% vs. 14.7% p=0.01) were all significantly associated with HD. Shock on admission was twice as common in patients developing HD (p<0.001). The only drugs associated with HD were piperacillin-tazobactam (p<0.001) and enalapril (p=0.04). On multivariable analysis however, HD was not associated with mortality. CONCLUSION HD was common in our study population, and was associated with other organ dysfunction, increased mortality and length of stay.
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Affiliation(s)
- A Saloojee
- Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
| | - D L Skinner
- Department of Anaesthetics and Critical Care, Perioperative Research Group, University of KwaZulu-Natal, South Africa.
| | - E Loots
- Department of Surgery, Inkosi Albert Luthuli Central Hospital and University of KwaZulu-Natal, South Africa
| | - T C Hardcastle
- University of KwaZulu-Natal Trauma Surgery Training Unit, Deputy Director: IALCH Trauma Service and Trauma ICU, KwaZulu-Natal Department of Health, South Africa
| | - D J J Muckart
- Department of Surgery, Nelson R Mandela School of Medicine, University of KwaZulu-Natal, South Africa
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48
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Abstract
Sepsis and septic shock are characterized by life-threatening organ dysfunction caused by a dysregulated host response to infection. The liver has a central role during sepsis, and is essential to the regulation of immune defence during systemic infections by mechanisms such as bacterial clearance, acute-phase protein or cytokine production and metabolic adaptation to inflammation. However, the liver is also a target for sepsis-related injury, including hypoxic hepatitis due to ischaemia and shock, cholestasis due to altered bile metabolism, hepatocellular injury due to drug toxicity or overwhelming inflammation, as well as distinct pathologies such as secondary sclerosing cholangitis in critically ill patients. Hence, hepatic dysfunction substantially impairs the prognosis of sepsis and serves as a powerful independent predictor of mortality in the intensive care unit. Sepsis is particularly problematic in patients with liver cirrhosis (who experience increased bacterial translocation from the gut and impaired microbial defence) as it can trigger acute-on-chronic liver failure - a syndrome with high short-term mortality. Here, we review the importance of the liver as a guardian, modifier and target of sepsis, the factors that contribute to sepsis in patients with liver cirrhosis and new therapeutic strategies.
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49
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Chaari A, Abdel Hakim K, Bousselmi K, Etman M, El Bahr M, El Saka A, Hamza E, Ismail M, Khalil EM, Kauts V, Casey WF. Pancreatic injury in patients with septic shock: A literature review. World J Gastrointest Oncol 2016; 8:526-531. [PMID: 27559431 PMCID: PMC4942740 DOI: 10.4251/wjgo.v8.i7.526] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/16/2016] [Revised: 04/26/2016] [Accepted: 05/27/2016] [Indexed: 02/05/2023] Open
Abstract
Sepsis and septic shock are life threatening condition associated with high mortality rate in critically-ill patients. This high mortality is mainly related to the inadequacy between oxygen delivery and cellular demand leading to the onset of multiorgan dysfunction. Whether this multiorgan failure affect the pancreas is not fully investigated. In fact, pancreatic injury may occur because of ischemia, overwhelming inflammatory response, oxidative stress, cellular apoptosis and/or metabolic derangement. Increased serum amylase and/or lipase levels are common in patients with septic shock. However, imaging test rarely reveal significant pancreatic damage. Whether pancreatic dysfunction does affect the prognosis of patients with septic shock or not is still a matter of debate. In fact, only few studies with limited sample size assessed the clinical relevance of the pancreatic injury in this group of patients. In this review, we aimed to describe the epidemiology and the physiopathology of pancreatic injury in septic shock patients, to clarify whether it requires specific management and to assess its prognostic value. Our main finding is that pancreatic injury does not significantly affect the outcome in septic shock patients. Hence, increased serum pancreatic enzymes without clinical features of acute pancreatitis do not require further imaging investigations and specific therapeutic intervention.
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50
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Rutter K, Horvatits T, Drolz A, Roedl K, Siedler S, Kluge S, Fuhrmann V. [Acute liver failure]. Med Klin Intensivmed Notfmed 2016; 113:174-183. [PMID: 27241777 PMCID: PMC7095899 DOI: 10.1007/s00063-016-0156-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2015] [Revised: 01/28/2016] [Accepted: 02/28/2016] [Indexed: 02/06/2023]
Abstract
Das akute Leberversagen (ALV) ist ein seltenes, aber lebensbedrohliches Zustandsbild. Charakteristisch ist das rasche Auftreten eines schweren Leberschadens mit hepatozellulärer Nekrose und eingeschränkter Leberfunktion. Bei weiterhin hoher Mortalität ist ein frühzeitiges Erkennen und Einleiten einer ursachenspezifischen unterstützenden sowie v. a. intensivmedizinischen symptomatischen Therapie essenziell. Durch Fortschritte im Bereich der intensivmedizinischen Behandlung von Patienten mit akutem Leberversagen sowie der Lebertransplantation konnte das Überleben deutlich verbessert werden.
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Affiliation(s)
- K Rutter
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland.
| | - T Horvatits
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - A Drolz
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - K Roedl
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - S Siedler
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - S Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
| | - V Fuhrmann
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Martinistraße 52, 20246, Hamburg, Deutschland
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