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Zhang Y, Hou L, Yuan D, Wu J, Wang Y, Yu Y, Meng C, Yang F, Yan H, Du Y, Zhu H, Walline JH, Jiang Y, Gao Y, Li Y. Liver injury in paraquat poisoning: A retrospective cohort study. Liver Int 2024. [PMID: 38963300 DOI: 10.1111/liv.16024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2023] [Revised: 06/19/2024] [Accepted: 06/23/2024] [Indexed: 07/05/2024]
Abstract
BACKGROUND AND AIMS Liver injury is one of the common complications of paraquat (PQ) poisoning, but whether the degree of liver injury is related to patient prognosis is still controversial. This study aimed to investigate whether liver injury was a risk factor for death in PQ-poisoned patients. METHODS We conducted a retrospective cohort study of PQ-poisoned patients from the past 10 years (2011-2020) from a large tertiary academic medical centre in China. PQ-poisoned patients were divided into a normal liver function group (n = 580) and a liver injury group (n = 60). Propensity score matching (PSM) analysis was then performed. RESULTS A total of 640 patients with PQ poisoning were included in this study. To reduce the impact of bias, dose of PQ, urinary PQ concentration and time from poisoning to hospital admission were matched between the two groups. A 3:1 PSM analysis was performed, ultimately including 240 patients. Compared with the normal liver function group, patients in the liver injury group were older, had a higher R value ([ALT/ULN]/[ALP/ULN]) (p < .001) and had a higher mortality rate. Cox regression analysis showed that there was no significant association between alanine aminotransferase, alkaline phosphatase, total bilirubin levels and hazard of death, but age, PQ dose, creatine kinase isoenzyme, creatine kinase, white blood cell count, neutrophil percentage and lymphocyte percentage were associated with mortality in patients with PQ poisoning. CONCLUSIONS The occurrence of liver injury within 48 h after PQ poisoning was a risk factor for mortality, and such liver injury was likely of a hepatocellular nature. Age, PQ dose, creatine kinase isoenzyme and white blood cell count were positively correlated with mortality, while creatine kinase, percentage of neutrophils and lymphocytes were inversely correlated.
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Affiliation(s)
- Yan Zhang
- Department of Emergency Medicine, Medical Key Laboratory of Poisoning Diseases of Henan Province, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Linlin Hou
- Department of Emergency Medicine, Medical Key Laboratory of Poisoning Diseases of Henan Province, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ding Yuan
- Department of Emergency Medicine, Medical Key Laboratory of Poisoning Diseases of Henan Province, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Jingtao Wu
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, China
| | - Yibo Wang
- Emergency Department, The 7th People's Hospital of Zhengzhou, Zhengzhou, China
| | - Yanwu Yu
- Department of Emergency Medicine, Medical Key Laboratory of Poisoning Diseases of Henan Province, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Cuicui Meng
- Department of Emergency Medicine, Medical Key Laboratory of Poisoning Diseases of Henan Province, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Fang Yang
- Department of Emergency Medicine, Medical Key Laboratory of Poisoning Diseases of Henan Province, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Hongyi Yan
- Department of Emergency Medicine, Medical Key Laboratory of Poisoning Diseases of Henan Province, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yuqi Du
- Department of Emergency Medicine, Medical Key Laboratory of Poisoning Diseases of Henan Province, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Huanzhou Zhu
- Department of Emergency Medicine, Medical Key Laboratory of Poisoning Diseases of Henan Province, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Joseph H Walline
- Department of Emergency Medicine, Penn State Health, Milton S. Hershey Medical Center and The Pennsylvania State University College of Medicine, Hershey, Pennsylvania, USA
| | - Yong Jiang
- Department of Emergency Medicine, Medical Key Laboratory of Poisoning Diseases of Henan Province, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanxia Gao
- Department of Emergency Medicine, Medical Key Laboratory of Poisoning Diseases of Henan Province, The First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yi Li
- Emergency Department, State Key Laboratory of Complex Severe and Rare Diseases, Peking Union Medical College Hospital, Peking Union Medical College, Chinese Academy of Medical Sciences, Beijing, China
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Rao S, Maddani SS, Chaudhuri S, Bhatt MT, Karanth S, Damani A, Rao K, Salins N. Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study. Indian J Crit Care Med 2024; 28:453-460. [PMID: 38738203 PMCID: PMC11080093 DOI: 10.5005/jp-journals-10071-24708] [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] [Received: 02/14/2024] [Accepted: 04/08/2024] [Indexed: 05/14/2024] Open
Abstract
Background Patients with paraquat poisoning (PP) have a mortality rate comparable to that of advanced malignancies, yet palliative care is seldom considered in these patients. This audit aimed to identify triggers for early palliative care referral in critically ill patients with PP. Methods Medical records of patients with PP were audited. Predictors of mortality within 48 hours of hospitalization and 24 hours of intensive care unit (ICU) admission were considered as triggers for palliative care referral. Results Among 108 patients, 84 complete records were analyzed, and 53 out of 84 (63.1%) expired. Within 48 hours after hospitalization, the lowest oxygen partial pressure in arterial blood to a fraction of inspired oxygen [the ratio of partial pressure of oxygen in arterial blood (PaO2) to the fraction of inspiratory oxygen concentration (FiO2) (PaO2/FiO2)] was the independent predictor of mortality, cut-off ≤ 197; the area under the curve (AUC), 0.924; sensitivity, 97%; specificity, 78%; p <0.001; and 95% confidence interval (CI): 0.878-0.978. Kaplan-Meier survival plot showed that the mean survival time of patients with the lowest PaO2/FiO2, ≤197, was 4.64 days vs 17.20 days with PaO2/FiO2 >197 (log-rank p < 0.001). Sequential organ failure assessment (SOFA) score within 24 hours of ICU admission had a cut-off ≥9; AUC, 0.980; p < 0.001; 95% CI: 0.955-1.000; 91% sensitivity; and 90% specificity for mortality prediction. Out of the total of 84 patients with PP analyzed, there were 11 patients admitted to the high dependency units (13.1%) and 73 patients admitted to the ICU (86.9%). Out of the total of 84 patients of PP in whom data was analyzed, 53 (63.1%) patients required ventilator support. All the 53 patients who required ventilator support due to worsening hypoxemia, eventually expired. Conclusion The lowest PaO2/FiO2 ≤ 197 within 48 hours of hospitalization, SOFA score ≥9 within 24 hours of ICU admission or need for mechanical ventilation are predictors of mortality in PP patients, who might benefit from early palliative care. How to cite this article Rao S, Maddani SS, Chaudhuri S, Bhatt MT, Karanth S, Damani A, et al. Utility of Clinical Variables for Deciding Palliative Care in Paraquat Poisoning: A Retrospective Study. Indian J Crit Care Med 2024;28(5):453-460.
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Affiliation(s)
- Shwethapriya Rao
- Department of Critical Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Sagar Shanmukhappa Maddani
- Department of Critical Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Souvik Chaudhuri
- Department of Critical Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Margiben T Bhatt
- Department of Critical Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Shubhada Karanth
- Department of General Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Anuja Damani
- Department of Palliative Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Krithika Rao
- Department of Palliative Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
| | - Naveen Salins
- Department of Palliative Care Medicine, Kasturba Medical College, Manipal, Manipal Academy of Higher Education, Manipal, Karnataka, India
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Tang G, Jiang Z, Xu L, Yang Y, Yang S, Yao R. Development and validation of a prognostic nomogram for predicting in-hospital mortality of patients with acute paraquat poisoning. Sci Rep 2024; 14:1622. [PMID: 38238454 PMCID: PMC10796350 DOI: 10.1038/s41598-023-50722-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2023] [Accepted: 12/23/2023] [Indexed: 01/22/2024] Open
Abstract
This study aimed to develop and validate a predictive model to determine the risk of in-hospital mortality in patients with acute paraquat poisoning. This retrospective observational cohort study included 724 patients with acute paraquat poisoning whose clinical data were collected within 24 h of admission. The primary outcome was in-hospital mortality. Patients were randomly divided into training and validation cohorts (7/3 ratio). In the training cohort, the least absolute shrinkage and selection operator regression models were used for data dimension reduction and feature selection. Multivariate logistic regression was used to generate a predictive nomogram for in-hospital mortality. The prediction model was assessed for both the training and validation cohorts. In the training cohort, decreased level of consciousness (Glasgow Coma Scale score < 15), neutrophil-to-lymphocyte ratio, alanine aminotransferase, creatinine, carbon dioxide combining power, and paraquat plasma concentrations at admission were identified as independent predictors of in-hospital mortality in patients with acute paraquat poisoning. The calibration curves, decision curve analysis, and clinical impact curves indicated that the model had a good predictive performance. It can be used on admission to the emergency department to predict mortality and facilitate early risk stratification and actionable measures in clinical practice after further external validation.
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Affiliation(s)
- Guo Tang
- Emergency Medicine Laboratory and the Department of Emergency, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Zhen Jiang
- Emergency Medicine Laboratory and the Department of Emergency, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Lingjie Xu
- Emergency Medicine Laboratory and the Department of Emergency, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Ying Yang
- Emergency Medicine Laboratory and the Department of Emergency, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Sha Yang
- Emergency Medicine Laboratory and the Department of Emergency, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China
| | - Rong Yao
- Emergency Medicine Laboratory and the Department of Emergency, West China Hospital, Sichuan University, No. 37 Guoxue Alley, Chengdu, 610041, Sichuan, China.
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Kobayashi T, Iwaki M, Nogami A, Yoneda M. Epidemiology and Management of Drug-induced Liver Injury: Importance of the Updated RUCAM. J Clin Transl Hepatol 2023; 11:1239-1245. [PMID: 37577239 PMCID: PMC10412691 DOI: 10.14218/jcth.2022.00067s] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2022] [Revised: 01/28/2023] [Accepted: 03/21/2023] [Indexed: 07/03/2023] Open
Abstract
Drug-induced liver injury (DILI) is a major cause of acute liver injury, liver failure, and liver transplantation worldwide. In recent years, immune checkpoint inhibitors have become widely used. This has led to an increase in DILI, for which pathophysiology and management methods differ significantly from the past. As the number of cases of acute liver injury and liver transplantation due to DILI is expected to increase, information about a DILI is becoming more valuable. DILI is classified into two types according to its etiology: intrinsic DILI, in which the drug or its metabolites cause liver damage that is dose-dependent and predictable; and idiosyncratic DILI, in which liver damage is also dose-independent but unpredictable. In addition, depending on the course of the disease, chronic DILI or drug-induced autoimmune hepatitis may be present. The number of DILI cases caused by antimicrobial agents is decreasing, whereas that caused by drugs for malignant tumors and health foods is increasing. The Roussel Uclaf Causality Assessment Method is widely used to assess causality in DILI. Liver injury is a type of immune-related adverse event. The pattern of hepatic injury in immune-related adverse events is mostly hepatocellular, but mixed type and bile stasis have also been reported. Sclerosing cholangitis caused by immune checkpoint inhibitors has also been reported as a unique type of injury. Treatment mainly comprises withdrawal of immune checkpoint inhibitors and steroid administration; however, mycophenolate mofetil may be considered if the disease is refractory to steroids.
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Affiliation(s)
- Takashi Kobayashi
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Michihiro Iwaki
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Asako Nogami
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
| | - Masato Yoneda
- Department of Gastroenterology and Hepatology, Yokohama City University Graduate School of Medicine, Yokohama, Japan
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Tajai P, Kornjirakasemsan A. Predicting mortality in paraquat poisoning through clinical findings, with a focus on pulmonary and cardiovascular system disorders. J Pharm Policy Pract 2023; 16:123. [PMID: 37864257 PMCID: PMC10588157 DOI: 10.1186/s40545-023-00635-z] [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: 07/20/2023] [Accepted: 10/15/2023] [Indexed: 10/22/2023] Open
Abstract
BACKGROUND Paraquat, one of the most widely used herbicides, poses a significant risk of mortality through self-poisoning and subsequent multiple organ failure. The primary objective aimed to identify the factors associated with death in patients poisoned by paraquat. METHODS A cross-sectional retrospective review was conducted at a tertiary referral hospital over five years. Eligible patients presented with acute paraquat toxicity between 1 January 2016 and 31 December 2020. Medical records of 148 patients were reviewed. RESULTS The in-hospital fatality rate was found to be 21.8%. Multivariate analysis revealed that the amount of paraquat ingested and clinical presentations, particularly pulmonary and cardiovascular system disorders, were significantly associated with mortality. CONCLUSION Our study highlights that the amount of paraquat ingested, along with the presence of pulmonary and cardiovascular system disorders, can serve as prognostic indicators for mortality rates in cases of paraquat poisoning. These findings have important implications for physicians in predicting the prognosis and mortality of paraquat poisoning patients.
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Affiliation(s)
- Preechaya Tajai
- Department of Forensic Medicine, Faculty of Medicine, Chiang Mai University, Chiang Mai, 50200, Thailand.
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Guo H, Yuan Y, Ma Y, Shi J, Gu H. Effects of early repeated hemoperfusion combined with hemodialysis on the prognosis of patients with paraquat poisoning. Am J Transl Res 2023; 15:5613-5623. [PMID: 37854212 PMCID: PMC10579036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/29/2023] [Indexed: 10/20/2023]
Abstract
OBJECTIVE To investigate the effect of early, repeated hemoperfusion in conjunction with hemodialysis on the health status, blood-gas indices, and prognosis of patients with paraquat (PQ) poisoning. METHODS In this retrospective study, clinical data of 149 PQ-poisoned patients treated at Xianyang First People's Hospital between January 2019 and January 2022 were analysed. Sixty-two patients who received conventional treatment coupled with early, repeated hemoperfusion were designated as the control group. The remaining 87 patients, who were subjected to additional hemodialysis on the basis of the control group, were designated in the experimental group. A comparison was made between the two groups regarding the changes in liver function, renal function, and blood-gas indices before and after the treatment. Three-month survival outcomes of both groups were analyzed using Cox regression, with survival curves drawn for different prognostic factors. RESULTS The experimental group exhibited significantly lower levels of indirect bilirubin (IBiL) and glutamic-pyruvic transaminase (ALT) after the treatment compared to the control group (all P < 0.05), as well as markedly lower levels of total bilirubin (TBil), direct bilirubin (DBil), glutamic-oxaloacetic transaminase (AST), alkaline phosphatase (ALP), urea nitrogen (BUN), and creatinine (Cr) (all P < 0.01). The experimental group also demonstrated significantly improved arterial partial pressure of oxygen (PaO2) and PaO2/inspired oxygen (FIO2) ratios, along with reduced arterial carbon dioxide partial pressure (PaCO2) after the treatment (all P < 0.05). Moreover, a significantly higher three-month survival rate was observed in the experimental group compared to the control group (P < 0.001). According to Cox regression analysis, blood purification mode, age, urine PQ concentration upon admission, the timing of initial gastric lavage and bowl cleanse, and the timing of initial blood purification were identified as independent factors affecting the patients' 90-day prognosis. CONCLUSION Early, repeated hemoperfusion coupled with hemodialysis significantly improves the blood-gas indices and liver and kidney function in patients with PQ poisoning, while also extending their short-term survival.
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Affiliation(s)
- Hao Guo
- Department of Critical Care Medicine, Xianyang First People’s HospitalXianyang 712000, Shaanxi, China
| | - Yaying Yuan
- Department of Critical Care Medicine, Xianyang First People’s HospitalXianyang 712000, Shaanxi, China
| | - Yanan Ma
- Emergency Department, Gansu Gem Flower HospitalLanzhou 730060, Gansu, China
| | - Jianling Shi
- Emergency Department, Gansu Gem Flower HospitalLanzhou 730060, Gansu, China
| | - Hua Gu
- Emergency Department, Gansu Gem Flower HospitalLanzhou 730060, Gansu, China
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