Incidence and outcome of ischemic hepatitis complicating septic shock

Sites and Causes of Infection in Patients with Sepsis-Associated Liver Dysfunction: A Population Study from the Medical Information Mart for Intensive Care III

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.

[Effects of cholestasis and hypoxic hepatitis on prognosis of ICU patients: a retrospective study based on MIMIC Ⅲ database]

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 &lt; 0.01), a higher hospital case fatality rate (40% vs 31%, P &lt; 0.01), and a higher ICU case fatality rate (35.7% vs 22.2%, P &lt; 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.

Successful Urgent Living Donor Liver Transplantation for Massive Liver Necrosis Accompanied by Nonocclusive Mesenteric Ischemia in a Biliary Atresia Infant: A Case Report

BACKGROUND

Treatment options for patients presenting with life-threatening splanchnic ischemia, including that of the intestine and liver, could previously only receive salvage surgery and attempted medical revascularization. We propose that urgent liver transplantation (LT) for acute liver failure (ALF) due to massive liver necrosis should be considered as a life-saving treatment. We successfully performed urgent living donor LT for nonocclusive hepatic ischemia accompanied by nonocclusive mesenteric ischemia (NOMI).

CASE

An 11-month-old boy with biliary atresia whose jaundice was re-elevated after Kasai portoenterostomy underwent cysto-jejunostomy. Three hours after the uneventful operation, tachycardia, hypotension, and unconsciousness suddenly occurred. Computed tomography revealed whole-liver and massive splenic and focal intestinal ischemia without any vessel occlusion. Urgent LT was performed on postoperative day 3 because intensive therapies, including prostaglandin E1 administration, blood transfusion, and continuous hemodiafiltration, were not effective and the patient had developed life-threatening bradycardia and hypotension. Intraoperative findings included whole-liver necrosis and splenic ischemia and segmental ileal necrosis without any vessel thrombus. LT and necrotic intestinal resections by end-to-end anastomosis were performed. Massive liver necrosis with Gram-positive cocci was histopathologically identified, indicating bacterial translocation due to NOMI. The post-LT course was uneventful, and the neurologic outcomes were uncomplicated.

CONCLUSIONS

Urgent LT was successfully completed for ALF with NOMI. LT is the sole treatment for the refractory ALF, and undelayed determination is important to rescue.

Shell-Free Copper Indium Sulfide Quantum Dots Induce Toxicity in Vitro and in Vivo

Semiconductor quantum dots (QDs) are attractive fluorescent contrast agents for in vivo imaging due to their superior photophysical properties, but traditional QDs comprise toxic materials such as cadmium or lead. Copper indium sulfide (CuInS₂, CIS) QDs have been posited as a nontoxic and potentially clinically translatable alternative; however, previous in vivo studies utilized particles with a passivating zinc sulfide (ZnS) shell, limiting direct evidence of the biocompatibility of the underlying CIS. For the first time, we assess the biodistribution and toxicity of unshelled CIS and partially zinc-alloyed CISZ QDs in a murine model. We show that bare CIS QDs breakdown quickly, inducing significant toxicity as seen in organ weight, blood chemistry, and histology. CISZ demonstrates significant, but lower, toxicity compared to bare CIS, while our measurements of core/shell CIS/ZnS are consistent with literature reports of general biocompatibility. In vitro cytotoxicity is dose-dependent on the amount of metal released due to particle degradation, linking degradation to toxicity. These results challenge the assumption that removing heavy metals necessarily reduces toxicity: indeed, we find comparable in vitro cytotoxicity between CIS and CdSe QDs, while CIS caused severe toxicity in vivo compared to CdSe. In addition to highlighting the complexity of nanotoxicity and the differences between the in vitro and in vivo outcomes, these unexpected results serve as a reminder of the importance of assessing the biocompatibility of core QDs absent the protective ZnS shell when making specific claims of compositional biocompatibility.

Liver Injury and Failure in Critical Illness

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.

Hypoxic hepatitis - its biochemical profile, causes and risk factors of mortality in critically-ill patients: A cohort study of 565 patients

PURPOSE

A retrospective analysis of critically-ill patients with hypoxic hepatitis (HH) to characterize the biochemical profile and to identify predictors of mortality using the Medical Information Mart for Intensive Care III database.

METHODS

HH was defined as a rapid increase in AST/ALT≥800IU/L after exclusion of other causes. We investigated the correlation between various clinical and laboratory parameters and mortality rates using regression models.

RESULTS

Among 38,645 ICU-patients, 565 (1.46%) were diagnosed with HH; 57.9% were males; median age was 63years. The unique biochemical profile of HH was confirmed; lactate dehydrogenase (LDH) was higher than both ALT and AST; AST>ALT for the first 2days then the ratio is reversed until recovery. All-cause hospital mortality was 44.1%. All-cause hospital mortality was 44.1%. On multivariate analysis, older age, higher SAPS-II, higher INR, higher bilirubin, higher LDH, acute kidney injury (AKI), and the need for vasopressors were independently associated with mortality.

CONCLUSION

Older age, higher SAPS-II, LDH, INR and bilirubin levels, concomitant AKI and the need for vasopressors were all factors associated with increased mortality. The diagnosis of HH was an important harbinger of mortality in this population, which appears to be driven mainly by the severity of the underlying conditions.

A prospective study on the causes of notably raised alanine aminotransferase (ALT)

OBJECTIVE

High levels of alanine aminotransferase (ALT) can be a marker of severe liver disease with variable aetiologies and prognosis. Very few prospective studies have been undertaken on the aetiology and prognosis of patients with high ALT levels. No population-based prospective study has systematically evaluated drug-induced liver injury (DILI) among these patients. The objective was to determine the aetiology and prognosis of patients with high ALT.

MATERIALS AND METHODS

In a catchment area of 160,000 inhabitants, a population-based prospective study identified all adult patients with serum level of ALT >500 U/L during a 12-month period. All underwent thorough diagnostic work-up and follow-up. In suspected DILI, causality was assessed with Roussel Uclaf Causality Assessment Method.

RESULTS

A total of 155 patients were identified with ALT >500 U/L, 12 children and one with ALT of non-liver-related origin, leaving 142 patients for the analysis: 73 (51%) males, median age 52 (IQR 36-68, range 19-89 years). The most common causes were choledocholithiasis 48/142 (34%), ischaemic hepatitis 26 (18%), viral hepatitis 16 (11%) and DILI 15 (11%), hepatobiliary malignancy (n = 6), surgery/interventions (n = 8) and other aetiologies (n = 23). No specific aetiology was found in 6% of cases. In the total study cohort 99 (70%) required hospitalisation, 78 (55%) had jaundice and 22 (16%) died, liver-related death in 10%, 35% in IH and 7% in DILI.

CONCLUSIONS

The most common cause of notably high ALT was choledocholithiasis. Ischaemic hepatitis was a common aetiology with approximately 35% liver-related mortality. Viral hepatitis and DILI were important aetiologies among these patients.

Role of Elevated Aminotransferases in ICU Patients with Rhabdomyolysis

To evaluate whether patients with rhabdomyolysis and serum alanine aminotransferase (ALT) and/or aspartate aminotransferase (AST) higher than 1000 IU/L had higher mortality that patients with low aminotransferases. Retrospective analysis of intensive care unit patients with rhabdomyolysis [creatine kinase (CK) higher than 5000 IU/L]. Patients were classified in two groups: low aminotransferases group, when AST and ALT were equal or lower to 1000 IU/L, and elevated aminotransferases group, when AST or ALT was above 1000 IU/L. Forty-six out of 189 patients included in the analysis (24.3%) had elevated aminotransferases. The mortality of patients with rhabdomyolysis was 25.9 per cent, being higher in patients with elevated aminotransferases compared with patients with low aminotransferases (60.9% vs 14.7%; P < 0.001). Mortality stratified by quartiles of CK in patients with low aminotransferases was independent of the level of CK ( P = 0.67). Logistic regression analysis showed that the independent variables associated with mortality were Simplified Acute Physiology Score II [1.11 (1.07–1.16) for each point of increase, P < 0.001], the international normalized ratio value [4.2 (1.6–10.7) for each point of increase, P = 0.003], and the need of renal replacement therapy [5.4 (1.7–17.2), P = 0.004]. Patients with rhabdomyolysis with elevated serum aminotransferases had higher mortality than patients with low serum aminotransferase levels.

Hypoxic hepatitis in cardiac intensive care unit: a study of cardiovascular risk factors, clinical course, and outcomes

Introduction

Hypoxic hepatitis (HH) is observed frequently in intensive care units. Information in the cardiac intensive care unit (CICU) is limited. The aim of this study was to analyze the clinical course and outcomes of HH in the specific setting of the CICU.

Methods

We analyzed records of patients with HH admitted to the CICU (Group 1). Data were collected and compared with those of an intermediate group of patients with altered liver test results that did not meet the HH criteria who had a serum aminotransferase level of five to ≤20 times the upper-normal limit (Group 2), and with a control group who had an aminotransferase level less than five times the upper-normal limit (Group 3).

Results

Patients with HH exhibited a worse hemodynamic profile and more of these patients were in shock: 17 (94.4%) in Group 1, 14 (77.8%) in Group 2, and seven (38.9%) in Group 3 (P=0.001). Cardiogenic shock was the most frequent event: 12 (66.7%) in Group 1, 13 (72.2%) in Group 2, and six (33.3%) in Group 3 (P=0.006). The mortality rate was 55.6%. Mechanical ventilation was an independent factor associated with death (odds ratio 12.25, 95% confidence interval 1.26–118.36).

Conclusion

The mortality rate of patients with HH in CICU is high and is associated with ventilatory disturbances.

Hypoxic liver injury and cholestasis in critically ill patients

PURPOSE OF REVIEW

Liver dysfunction frequently complicates the clinical picture of critical illness and leads to increased morbidity and mortality. The purpose of this review is to characterize the most frequent patterns of liver dysfunction at the intensive care unit, cholestasis and hypoxic liver injury (HLI), and to illustrate its clinical impact on outcome in critically ill patients.

RECENT FINDINGS

Liver dysfunction at the intensive care unit can be divided into two main patterns: cholestatic and HLI, also known as ischemic hepatitis or shock liver. Both hepatic dysfunctions occur frequently and early in critical illness. Major issues are the early recognition and subsequent initiation of therapeutic measures.

SUMMARY

Clinical awareness of the liver not only as a victim, but also as a trigger of multiorgan failure is of central clinical importance. Physicians have to identify the underlying factors that contribute to its development to initiate curative measures as early as possible.

Hypoxic hepatitis

Hypoxic hepatitis (HH), an acute liver injury also known as 'ischaemic hepatitis' or 'shock liver', is frequently observed in intensive care units. HH is heralded by a massive but transient rise in serum aminotransferase activities caused by anoxic necrosis of centrilobular liver cells. Cardiac failure, respiratory failure and toxic-septic shock are the main underlying conditions accounting for more than 90% of cases, but HH may also occur in other circumstances. Until recently, liver ischaemia, i.e. a drop in hepatic blood flow, was considered the leading, and even the sole, hemodynamic mechanism responsible for HH, and it was generally held that a shock state was required. In reality, other hemodynamic mechanisms of hypoxia, such as passive congestion of the liver, arterial hypoxaemia and dysoxia, play an important role while a shock state is observed in only 50% of cases. Accordingly, 'ischaemic hepatitis' and 'shock liver' are misnomers. Therapy of HH depends primarily on the nature of the underlying condition. The prognosis is poor, with more than half of patients dying during the hospital stay.

Extracorporeal artificial liver support in hypoxic liver injury

The incidence of hypoxic liver injury, most commonly referred to as hypoxic hepatitis (HH), is up to 10% in critically ill patients. In the majority of cases, HH occurs as a consequence of haemodynamic impairment following cardiogenic or septic shock. A marked, dramatic increase in the aminotransferase levels in a setting of cardiocirculatory failure is the key characteristic of HH. HH may contribute to several complications such as hepatopulmonary syndrome and hypoglycaemia. The overall mortality after the onset of HH is approximately 50-60% within 1 month. We report a case of severe HH that was successfully bridged using the Molecular Adsorbent Recirculating System. In addition to the possible effects of extracorporeal liver support devices, the recognition of HH and therapy of the underlying disease that led to the occurrence of HH is of central importance.

Hypoxic hepatitis in critically ill patients: incidence, etiology and risk factors for mortality

PURPOSE

Hypoxic hepatitis may be induced by hemodynamic instability or arterial hypoxemia in critically ill patients. We investigated the incidence, etiology, association with systemic ischemic injury and risk factors for mortality in this population.

METHODS

Retrospective analysis of patients with hypoxic hepatitis admitted to a multidisciplinary intensive care unit (ICU) of a university hospital. Hypoxic hepatitis was defined as the existence of a compatible clinical setting (cardiocirculatory failure or arterial hypoxemia) and aminotransferase levels higher than 1000 IU/L.

RESULTS

During the 8-year study period, 182 out of the 7674 patients admitted presented hypoxic hepatitis (2.4%). The most common cause was septic shock. The rate of in-hospital mortality in hypoxic hepatitis was 61.5% (112 patients), and was higher in patients with septic shock (83.3%) and cardiac arrest (77.7%). Ischemic pancreatitis (25.6%), rhabdomyolysis (41.2%) and renal failure (67.2%) were common in these patients. Risk factors of mortality were prolonged INR (p = 0.005), need for renal replacement therapy (p = 0.001) and septic shock (p = 0.005).

CONCLUSIONS

Hypoxic hepatitis was not a rare condition, and was frequently accompanied by multiorgan injury, with high mortality. Risk factors for increased mortality were prolonged INR, need for renal replacement therapy, and septic shock.