Plasma Lactate Dehydrogenase Levels Predict Mortality in Acute Aortic Syndromes: A Diagnostic Accuracy and Observational Outcome Study

Impact of lactate dehydrogenase on prognosis of patients undergoing cardiac surgery

Background

Lactate dehydrogenase (LDH) has been reported in multiple heart diseases. Herein, we explored the prognostic effects of preoperative LDH on adverse outcomes in cardiac surgery patients.

Methods

Retrospective data analysis was conducted from two large medical databases: Medical Information Mart for Intensive Care (MIMIC) III and MIMIC IV databases. The primary outcome was in-hospital mortality, whereas the secondary outcomes were 1-year mortality, continuous renal replacement therapy, prolonged ventilation, and prolonged length of intensive care unit and hospital stay.

Results

Patients with a primary endpoint had significantly higher levels of LDH (p < 0.001). Multivariate regression analysis presented that elevated LDH was independently correlated with increased risk of primary and secondary endpoints (all p < 0.001). Subgroup analyses showed that high LDH was consistently associated with primary endpoint. Moreover, LDH exhibited the highest area under the curve (0.768) for the prediction of primary endpoint compared to the other indicators, including neutrophil–lymphocyte ratio (NLR), lymphocyte-monocyte ratio (LMR), platelet–lymphocyte ratio (PLR), lactate, and simplified acute physiology score (SAPS) II. The above results were further confirmed in the MIMIC IV dataset.

Conclusions

Elevated preoperative LDH may be a robust predictor of poor prognosis in cardiac surgery patients, and its predictive ability is superior to NLR, LMR, PLR, lactate, and SAPS II.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12872-022-02848-7.

Machine learning-based in-hospital mortality prediction models for patients with acute coronary syndrome

OBJECTIVES

The purpose of this study is to identify the risk factors of in-hospital mortality in patients with acute coronary syndrome (ACS) and to evaluate the performance of traditional regression and machine learning prediction models.

METHODS

The data of ACS patients who entered the emergency department of Fujian Provincial Hospital from January 1, 2017 to March 31, 2020 for chest pain were retrospectively collected. The study used univariate and multivariate logistic regression analysis to identify risk factors for in-hospital mortality of ACS patients. The traditional regression and machine learning algorithms were used to develop predictive models, and the sensitivity, specificity, and receiver operating characteristic curve were used to evaluate the performance of each model.

RESULTS

A total of 6482 ACS patients were included in the study, and the in-hospital mortality rate was 1.88%. Multivariate logistic regression analysis found that age, NSTEMI, Killip III, Killip IV, and levels of D-dimer, cardiac troponin I, CK, N-terminal pro-B-type natriuretic peptide (NT-proBNP), high-density lipoprotein (HDL) cholesterol, and Stains were independent predictors of in-hospital mortality. The study found that the area under the receiver operating characteristic curve of the models developed by logistic regression, gradient boosting decision tree (GBDT), random forest, and support vector machine (SVM) for predicting the risk of in-hospital mortality were 0.884, 0.918, 0.913, and 0.896, respectively. Feature importance evaluation found that NT-proBNP, D-dimer, and Killip were top three variables that contribute the most to the prediction performance of the GBDT model and random forest model.

CONCLUSIONS

The predictive model developed using logistic regression, GBDT, random forest, and SVM algorithms can be used to predict the risk of in-hospital death of ACS patients. Based on our findings, we recommend that clinicians focus on monitoring the changes of NT-proBNP, D-dimer, Killip, cTnI, and LDH as this may improve the clinical outcomes of ACS patients.

Identifying key predictors of mortality in young patients on chronic haemodialysis-a machine learning approach

BACKGROUND

The mortality risk remains significant in paediatric and adult patients on chronic haemodialysis (HD) treatment. We aimed to identify factors associated with mortality in patients who started HD as children and continued HD as adults.

METHODS

The data originated from a cohort of patients <30 years of age who started HD in childhood (≤19 years) on thrice-weekly HD in outpatient DaVita dialysis centres between 2004 and 2016. Patients with at least 5 years of follow-up since the initiation of HD or death within 5 years were included; 105 variables relating to demographics, HD treatment and laboratory measurements were evaluated as predictors of 5-year mortality utilizing a machine learning approach (random forest).

RESULTS

A total of 363 patients were included in the analysis, with 84 patients having started HD at <12 years of age. Low albumin and elevated lactate dehydrogenase (LDH) were the two most important predictors of 5-year mortality. Other predictors included elevated red blood cell distribution width or blood pressure and decreased red blood cell count, haemoglobin, albumin:globulin ratio, ultrafiltration rate, z-score weight for age or single-pool Kt/V (below target). Mortality was predicted with an accuracy of 81%.

CONCLUSIONS

Mortality in paediatric and young adult patients on chronic HD is associated with multifactorial markers of nutrition, inflammation, anaemia and dialysis dose. This highlights the importance of multimodal intervention strategies besides adequate HD treatment as determined by Kt/V alone. The association with elevated LDH was not previously reported and may indicate the relevance of blood-membrane interactions, organ malperfusion or haematologic and metabolic changes during maintenance HD in this population.

Comparison between Different Tricuspid Valve Procedures through Postoperative Inflammation and Myocardial Enzymes

Introduction

The thoracoscopic procedure for tricuspid valve (TV) diseases is a minimally invasive method of treatment. This study focuses on comparing the changes in postoperative inflammatory reaction and myocardial injury markers after thoracoscopic and sternotomy/thoracotomy TV procedures.

Methods

We retrospectively analyzed 88 patients (53 males, aged 50.9±16.2 years) with TV diseases (single-valve disease) (72 cases of TV plasty) between January 2018 and April 2019. A total of 56 patients underwent thoracoscopic procedure (50 cases of TV plasty). The leukocyte and C-reactive protein (CRP) levels were monitored as indicators of systemic inflammatory reaction. The lactate dehydrogenase, creatine kinase, creatine kinase myocardial band, aspartate aminotransferase, and troponin-T levels were recorded as markers of myocardial injury.

Results

The CRP and white blood cells levels of patients in the sternotomy approach group were continuously higher than those in patients in the thoracoscopic approach group. And the levels of myocardial enzymes in patients in the thoracoscopic approach group were significantly lower than those in patients in the sternotomy approach group.

Conclusion

Compared with sternotomy/thoracotomy procedures on TV, the thoracoscopic procedure can reduce postoperative myocardial injury significantly and systemic inflammatory reaction to a certain extent. It is technically feasible, safe, effective, and worthy of widespread adoption in clinical practice.

Diagnosis and management of acute aortic syndromes in the emergency department

Acute aortic syndromes (AASs) are deadly cardiovascular emergencies involving the thoracic aorta. AASs are relatively rare conditions, have unspecific signs and symptoms (including truncal pain, syncope, neurologic deficit and limb ischemia) and require contrast-enhanced tomography angiography (CTA) of the chest and abdomen for conclusive diagnosis and subsequent therapeutic planning. In the Emergency Department (ED), most patients with potential signs/symptoms of AASs are finally found affected by other alternative diagnoses. Hence, misdiagnosis and delayed diagnosis of AASs are major concerns. In critically ill patients, decision to perform CTA is usually straightforward, as exam benefits largely outweigh risks. In patients with ST-tract elevation on ECG, suspected primary ischemic stroke and in stable patients (representing the most prevalent ED scenarios), proper selection of patients necessitating CTA is cumbersome, due to concurrent risks of misdiagnosis and over-testing. Available studies support an algorithm integrating clinical probability assessment, bedside echocardiography and D-dimer (if the clinical probability is not high). Therapeutic management includes medical therapy for all patients including an opioid and anti-impulse drugs (a beta-blocker and a vasodilator), targeting a heart rate of 60 bpm and systolic blood pressure of 100-120 mmHg. Patients with AASs involving the ascending aorta are likely candidate for urgent surgery, and complicated type B AASs (severe aortic dilatation, impending or frank rupture, organ malperfusion, refractory pain, severe hypertension) necessitate evaluation for urgent endovascular treatment. For uncomplicated type B AASs, optimal medical therapy is the current standard of care.

Management of Lower Limb Ischemia During Operative Repair of Acute Type A Aortic Dissection by Distal Crossover Grafts: a Case Series

Objective

To describe our experience of nine patients with extra-anatomical bypass for clinically ischemic distal limb during repair of acute Type A aortic dissection (ATAAD).

Methods

We retrospectively examined a series of nine patients who underwent surgery for ATAAD. We identified a subset of the patients who presented with concomitant radiographic and clinical signs of lower limb ischemia. All but one patient (axillobifemoral bypass) underwent femorofemoral crossover grafting by the cardiac surgeon during cooling.

Results

One hundred eighty-one cases of ATAAD underwent surgery during the study period with a mortality of 19.3%. Nine patients had persistent clinical evidence of lower limb ischemia (4.9%) and underwent extra-anatomical bypass during cooling. Two patients underwent additional fasciotomies. Mean delay from symptoms to surgery in these nine patients was 9.5 hours. Two patients had bilateral amputations despite revascularisation and, of note, had long delays in presentation for surgery (> 12 hours). There were no mortalities during these inpatient episodes. Outpatient radiographic follow-up at the first opportunity demonstrated 100% patency.

Conclusion

Our experience suggests that, during complicated aortic dissection, limb ischemia may have a devastating outcome including amputation when diagnosis and referral are delayed. Early diagnosis and surgery are crucial in preventing this potentially devastating complication.

Impact of Total Psoas Area and Lean Muscular Area on Mortality after Endovascular Aortic Aneurysm Repair

BACKGROUND

Sarcopenia has assumed growing relevance as a morbimortality predictor after major abdominal surgery. The aim of this study is to access total psoas muscle area (TPA) and lean muscle area (LMA) impact in morbimortality after elective endovascular abdominal aortic aneurysm repair (EVAR).

METHODS

Asymptomatic patients submitted to aortic endoprosthesis implantation between January 1, 2014 and December 31, 2018 at our vascular surgery department were retrospectively evaluated. After exclusion criteria were applied, 105 patients were included in the study; preoperative computed tomography scans were evaluated using OSIRIX software (Bernex, Switzerland). Two observers independently calculated TPA at the most caudal level of the L3 vertebra and respective density, therefore calculating LMA. Patients were separated by tertiles with the lowest being considered sarcopenic and with higher muscle steatosis and compared with the higher tertiles. Patient demographics and intraoperative and postoperative period variables were collected. Charlson comorbidity index was calculated and surgical complications classified according to Clavien-Dindo. The intraclass correlation coefficient and Bland-Altman plot were made to characterize interobserver variability. Survival analysis was performed with the Kaplan-Meier method, and differences between survival curves were tested with the log-rank test. The effect of sarcopenia on patient survival was assessed using Cox proportional hazard models.

RESULTS

Considering TPA, univariate analyses revealed that patients in the lower tertile had inferior survival (P = 0.03), whereas multivariate analyses showed increased likelihood of mortality (P = 0.039, hazard ratio (HR) 3.829). For LMA, univariate analyses revealed that patients in the lower tertile had inferior survival (P = 0.013), whereas multivariate analyses showed increased likelihood of mortality (P = 0.026, HR 4.153). When analyzing patients in the lowest tertile of both TPA and LMA, both univariate (P = 0.002) and multivariate (P = 0.018, HR 4.166) analyses reveled inferior survival.

CONCLUSIONS

Our study reveals reduced survival in patients with low TPA and low LMA submitted to elective EVAR; these factors should probably be taken into consideration in the future for preoperative risk evaluation and surgical planning.

A decision support system for the prediction of mortality in patients with acute kidney injury admitted in intensive care unit

Intensive care unit (ICU) is a very special unit of a hospital, where healthcare professionals provide treatment and, later, close follow-up to the patients. It is crucial to estimate mortality in ICU patients from many viewpoints. The purpose of this study is to classify the status of patients with acute kidney injury (AKI) in ICU as early mortality, late mortality, and survival by the application of Classification and Regression Trees (CART) algorithm to the patients' attributes such as blood urea nitrogen, creatinine, serum and urine neutrophil gelatinase-associated lipocalin (NGAL), alkaline phosphatase, lactate dehydrogenase (LDH), gamma-glutamyl transferase, laboratory electrolytes, blood gas, mean arterial pressure, central venous pressure and demographic details of patients. This study was conducted 50 patients with AKI who were followed up in the ICU. The study also aims to determine the significance of relationship between the attributes used in the prediction of mortality in CART and patients' status by employing the Kruskal-Wallis H test. The classification accuracy, sensitivity, and specificity of CART for the tested attributes for the prediction of early mortality, late mortality, and survival of patients were 90.00%, 83.33%, and 91.67%, respectively. The values of both urine NGAL and LDH on day 7 showed a considerable difference according to the patients' status after being examined by the Kruskal-Wallis H test.

Association of Lactate Dehydrogenase with In-Hospital Mortality in Patients with Acute Aortic Dissection: A Retrospective Observational Study

Background

Evidence regarding the relationship between serum lactate dehydrogenase (LDH) levels and in-hospital mortality in acute aortic dissection (AAD) patients is extremely limited. We aimed to investigate the relationship between LDH and in-hospital mortality in AAD patients.

Methods

The present study was a retrospective observational study. A total of 1526 participants with acute aortic dissection were involved in a hospital in China from January 2014 to December 2018. The target-independent variable was LDH measured at baseline, and the dependent was all-cause mortality during hospitalization. Covariates involved in this study included age, gender, body mass index (BMI), hypertension, diabetes, smoking, stroke, atherosclerosis, systolic blood pressure (SBP), diastolic blood pressure (DBP), white blood cell (WBC), hemoglobin (Hb), alanine transaminase (ALT), aspartate aminotransferase (AST), albumin (ALB), creatinine (Cr), symptom, type of AAD (Stanford), and management.

Results

The average age of 1526 selected participants was 52.72 ± 11.94 years old, and about 80.41% of them were male. The result of the fully adjusted model showed LDH was positively associated with in-hospital mortality in AAD patients after adjusting confounders (OR = 1.09, 95% CI 1.05 to 1.13). A nonlinear relationship was detected between LDH and in-hospital mortality in AAD patients after adjusting for potential confounders (age, gender, BMI, hypertension, diabetes, stroke, atherosclerosis, smoking, symptom, SBP, DBP, WBC, Hb, ALT, AST, ALB, Cr, type of AAD (Stanford), and management), whose point was 557. The effect sizes and the confidence intervals of the left and right sides of the inflection point were 0.90 (0.74–1.10) and 1.12 (1.06–1.19), respectively. Subgroup analysis in participants showed that the relationship between LDH and in-hospital mortality was stable, and all of the P value for the interaction in different subgroup were more than 0.05.

Conclusions

The relationship between LDH and in-hospital mortality in AAD patients is nonlinear. LDH was positively related with in-hospital mortality when LDH is more than 557.

Effect and Mechanism of Ganoderma lucidum Spores on Alleviation of Diabetic Cardiomyopathy in a Pilot in vivo Study

BACKGROUND

Ganoderma lucidum spores (GLS) exhibit disease prevention properties, but no study has been carried out on the anti-diabetic cardiomyopathy property of GLS. The aim of this study was to evaluate the hyperglycemia-mediated cardiomyopathy protection and mechanisms of GLS in streptozotocin (STZ)induced diabetic rats.

METHODS

Male SD rats were randomly divided into three groups. Two groups were given STZ (50 mg/kg, i.p.) treatment and when their fasting plasma glucose was above 16.7 mmol/L, among them, one group was given placebo, as diabetic group, and another group was given GLS (300 mg/kg) treatment. The group without STZ treatment was given placebo as a control group. The experiment lasted 70 days. The histology of myocardium and biomarkers of antioxidants, myocardial injury, pro-inflammatory cytokines, pro-apoptotic proteins and phosphorylation of key proteins in PI3K/AKT pathway were assessed.

RESULTS

Biochemical analysis showed that GLS treatment significantly reduced the blood glucose (-20.3%) and triglyceride (-20.4%) levels compared to diabetic group without treatment. GLS treatment decreased the content of MDA (-25.6%) and activity of lactate dehydrogenase (-18.9%) but increased the activity of GSH-Px (65.4%). Western blot analysis showed that GLS treatment reduced the expression of both alpha-smooth muscle actin and brain natriuretic peptide. Histological analysis on the cardiac tissue micrographs showed that GLS treatment reduced collagen fibrosis and glycogen reactivity in myocardium. Both Western blot and immunohistochemistry analyses showed that GLS treatment decreased the expression levels of pro-inflammatory factors (cytokines IL-1β, and TNF-α) as well as apoptosis regulatory proteins (Bax, caspase-3 and -9), but increased Bcl-2. Moreover, GLS treatment significantly increased the phosphorylation of key proteins involved in PI3K/AKT pathway, eg, p-AKT p-PI3K and mTOR.

CONCLUSION

The results indicated that GLS treatment alleviates diabetic cardiomyopathy by reducing hyperglycemia, oxidative stress, inflammation, apoptosis and further attenuating the fibrosis and myocardial dysfunction induced by STZ through stimulation of the PI3K/Akt/mTOR signaling pathway.

Urinary versus plasma neutrophil gelatinase-associated lipocalin (NGAL) as a predictor of mortality for acute kidney injury in intensive care unit patients

OBJECTIVE

To examine urinary and plasma neutrophil gelatinase-associated lipocalin (NGAL) levels in predicting ICU mortality.

DESIGN

Prospective observational.

SETTING

University Critical Care setting.

PARTICIPANTS

50 patients with acute kidney injury (AKI).

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Serial urinary and plasma concentrations of NGAL were measured. Twenty-five patients had early progression (EP) and 25 patients had early improvement (EI) of AKI. Plasma concentrations of NGAL in the EP group (N=25) were significantly higher than those in the EI group (129 [IQR; 20] vs. 111 [IQR; 32] ng/mL; P=0.009), while urine NGAL levels on admission were similar in both groups (61 [IQR; 20] vs. 65 [IQR; 20] ng/mL; P=0.767). Plasma NGAL concentrations rapidly decreased to 87 [32] ng/mL in the EI group (P<0.001) and while it remained elevated in the EP group (138 [21] ng/mL). Within 28-days, 50% of the patients died in the EP group, whereas no patient died in the EI group (P<0.001). Plasma NGAL was a fair predictor for progression of AKI (AUC; 0.719±0.063; P=0.006). 48-hour changes in plasma NGAL levels predicted death within 28-days of ICU admission (AUC; 0.874±0.048; P<0.001).

CONCLUSION

Early progression of AKI was associated with more death within 28 and 90days. While one time measurement of plasma NGAL levels at the time ICU admission may represent the kidney health status in critical care settings, it does not reliably predict mortality. On the other hand, changes in plasma NGAL within 48h of admission improve the value of this biomarker in predicting ICU mortality.

Towards frailty biomarkers: Candidates from genes and pathways regulated in aging and age-related diseases

OBJECTIVE

Use of the frailty index to measure an accumulation of deficits has been proven a valuable method for identifying elderly people at risk for increased vulnerability, disease, injury, and mortality. However, complementary molecular frailty biomarkers or ideally biomarker panels have not yet been identified. We conducted a systematic search to identify biomarker candidates for a frailty biomarker panel.

METHODS

Gene expression databases were searched (http://genomics.senescence.info/genes including GenAge, AnAge, LongevityMap, CellAge, DrugAge, Digital Aging Atlas) to identify genes regulated in aging, longevity, and age-related diseases with a focus on secreted factors or molecules detectable in body fluids as potential frailty biomarkers. Factors broadly expressed, related to several "hallmark of aging" pathways as well as used or predicted as biomarkers in other disease settings, particularly age-related pathologies, were identified. This set of biomarkers was further expanded according to the expertise and experience of the authors. In the next step, biomarkers were assigned to six "hallmark of aging" pathways, namely (1) inflammation, (2) mitochondria and apoptosis, (3) calcium homeostasis, (4) fibrosis, (5) NMJ (neuromuscular junction) and neurons, (6) cytoskeleton and hormones, or (7) other principles and an extensive literature search was performed for each candidate to explore their potential and priority as frailty biomarkers.

RESULTS

A total of 44 markers were evaluated in the seven categories listed above, and 19 were awarded a high priority score, 22 identified as medium priority and three were low priority. In each category high and medium priority markers were identified.

CONCLUSION

Biomarker panels for frailty would be of high value and better than single markers. Based on our search we would propose a core panel of frailty biomarkers consisting of (1) CXCL10 (C-X-C motif chemokine ligand 10), IL-6 (interleukin 6), CX3CL1 (C-X3-C motif chemokine ligand 1), (2) GDF15 (growth differentiation factor 15), FNDC5 (fibronectin type III domain containing 5), vimentin (VIM), (3) regucalcin (RGN/SMP30), calreticulin, (4) PLAU (plasminogen activator, urokinase), AGT (angiotensinogen), (5) BDNF (brain derived neurotrophic factor), progranulin (PGRN), (6) α-klotho (KL), FGF23 (fibroblast growth factor 23), FGF21, leptin (LEP), (7) miRNA (micro Ribonucleic acid) panel (to be further defined), AHCY (adenosylhomocysteinase) and KRT18 (keratin 18). An expanded panel would also include (1) pentraxin (PTX3), sVCAM/ICAM (soluble vascular cell adhesion molecule 1/Intercellular adhesion molecule 1), defensin α, (2) APP (amyloid beta precursor protein), LDH (lactate dehydrogenase), (3) S100B (S100 calcium binding protein B), (4) TGFβ (transforming growth factor beta), PAI-1 (plasminogen activator inhibitor 1), TGM2 (transglutaminase 2), (5) sRAGE (soluble receptor for advanced glycosylation end products), HMGB1 (high mobility group box 1), C3/C1Q (complement factor 3/1Q), ST2 (Interleukin 1 receptor like 1), agrin (AGRN), (6) IGF-1 (insulin-like growth factor 1), resistin (RETN), adiponectin (ADIPOQ), ghrelin (GHRL), growth hormone (GH), (7) microparticle panel (to be further defined), GpnmB (glycoprotein nonmetastatic melanoma protein B) and lactoferrin (LTF). We believe that these predicted panels need to be experimentally explored in animal models and frail cohorts in order to ascertain their diagnostic, prognostic and therapeutic potential.

Serum lactate dehydrogenase is predictive of persistent organ failure in acute pancreatitis

PURPOSE

Elevated serum lactate dehydrogenase (LDH) has been reported in a serious of clinical diseases. However, the relationship between LDH and the incidence of persistent organ failure (POF) in acute pancreatitis (AP) has not been characterized.

MATERIALS AND METHODS

A total of 105 patients with AP who presented within 72h from symptom onset between 2014 and 2015 were included in this retrospective study. Demographic parameters and laboratory data on admission were compared between patients with and without POF. Multivariable logistic regression analyses were utilized to evaluate the prognostic value of LDH for predicting POF.

RESULTS

21 patients were diagnosed with POF. Compared to non-POF, patients with POF showed a significantly higher value of serum LDH on admission (741.57±331.72 vs. 296.08±135.73U/L, P<0.001). After multivariate logistic analysis, LDH remained an independent risk factor for POF (Hazard ratio 4.38, 95%CI: 1.42-13.47; P=0.010). A LDH value of 647U/L predicted POF with an area under the curve (AUC) of 0.876, a sensitivity with 76.2% and specificity with 98.8%, respectively.

CONCLUSIONS

Our results indicate that serum LDH on admission is independently associated with POF in AP and may serve as a potential prognostic factor.