Favorable 90-Day Mortality in Obese Caucasian Patients with Septic Shock According to the Sepsis-3 Definition

Associations between body mass index and all-cause mortality: A systematic review and meta-analysis

Fasting insulin and c-reactive protein confound the association between mortality and body mass index. An increase in fat mass may mediate the associations between hyperinsulinemia, hyperinflammation, and mortality. The objective of this study was to describe the "average" associations between body mass index and the risk of mortality and to explore how adjusting for fasting insulin and markers of inflammation might modify the association of BMI with mortality. MEDLINE and EMBASE were searched for studies published in 2020. Studies with adult participants where BMI and vital status was assessed were included. BMI was required to be categorized into groups or parametrized as non-first order polynomials or splines. All-cause mortality was regressed against mean BMI squared within seven broad clinical populations. Study was modeled as a random intercept. β coefficients and 95% confidence intervals are reported along with estimates of mortality risk by BMIs of 20, 30, and 40 kg/m2 . Bubble plots with regression lines are drawn, showing the associations between mortality and BMI. Splines results were summarized. There were 154 included studies with 6,685,979 participants. Only five (3.2%) studies adjusted for a marker of inflammation, and no studies adjusted for fasting insulin. There were significant associations between higher BMIs and lower mortality risk in cardiovascular (unadjusted β -0.829 [95% CI -1.313, -0.345] and adjusted β -0.746 [95% CI -1.471, -0.021]), Covid-19 (unadjusted β -0.333 [95% CI -0.650, -0.015]), critically ill (adjusted β -0.550 [95% CI -1.091, -0.010]), and surgical (unadjusted β -0.415 [95% CI -0.824, -0.006]) populations. The associations for general, cancer, and non-communicable disease populations were not significant. Heterogeneity was very large (I2  ≥ 97%). The role of obesity as a driver of excess mortality should be critically re-examined, in parallel with increased efforts to determine the harms of hyperinsulinemia and chronic inflammation.

Differences in Mortality and Sepsis-Associated Organ Dysfunction between Surgical and Non-Surgical Sepsis Patients

(1) Background: Patients with sepsis following surgical intervention may exhibit fundamental distinctions from those experiencing sepsis without prior surgery. Despite the potential clinical importance of distinguishing these two sepsis subpopulations, dissimilarities, particularly in outcome, between surgical and non-surgical patients have been subject to limited scientific investigations in the existing literature. This study aimed to investigate the differences in mortality and sepsis-associated organ dysfunction between these two groups. (2) Methods: A retrospective analysis was conducted using data from a large cohort of prospectively enrolled patients with sepsis (n = 737) admitted to three intensive care units at University Medical Center Goettingen; patients were categorized into surgical (n = 582) and non-surgical sepsis groups (n = 155). The primary outcomes assessed were 28- and 90-day mortality rates, and secondary endpoints were multiple clinical parameters and measures of sepsis-associated organ dysfunction. (3) Results: Non-surgical patients presented a significantly higher 90-day mortality (37%) compared to surgical sepsis patients (30%, p = 0.0457). Moreover, the non-surgical sepsis group exhibited increased sepsis-associated organ dysfunction, as evidenced by higher average SOFA scores (p < 0.001), elevated levels of serum Procalcitonin (p = 0.0102), and a higher utilization of organ replacement therapies such as ventilation (p < 0.001), vasopressor treatment (p < 0.001), and renal replacement therapy (p = 0.0364). Additionally, non-surgical sepsis patients had higher organ-specific SOFA respiratory (p < 0.001), cardiovascular (p < 0.001), renal (p < 0.001), coagulation (0.0335), and central nervous system (p = 0.0206) subscores. (4) Conclusions: These results suggested that patients with non-surgical sepsis may face distinct challenges and a higher risk of adverse outcomes compared to patients with sepsis following surgical intervention. These findings have important implications for clinical decision-making, patient management, and resource allocation in sepsis care.

Obesity Paradox and Functional Outcomes in Sepsis: A Multicenter Prospective Study

OBJECTIVES

In Asian populations, the correlation between sepsis outcomes and body mass is unclear. A multicenter, prospective, observational study conducted between September 2019 and December 2020 evaluated obesity's effects on sepsis outcomes in a national cohort.

SETTING

Nineteen tertiary referral hospitals or university-affiliated hospitals in South Korea.

PATIENTS

Adult patients with sepsis ( n = 6,424) were classified into obese ( n = 1,335) and nonobese groups ( n = 5,089).

MEASUREMENTS AND RESULTS

Obese and nonobese patients were propensity score-matched in a ratio of 1:1. Inhospital mortality was the primary outcome. After propensity score matching, the nonobese group had higher hospital mortality than the obese group (25.3% vs 36.7%; p < 0.001). The obese group had a higher home discharge rate (70.3% vs 65.2%; p < 0.001) and lower median Clinical Frailty Scale (CFS) (4 vs 5; p = 0.007) at discharge than the nonobese group, whereas the proportion of frail patients at discharge (CFS ≥ 5) was significantly higher in the nonobese group (48.7% vs 54.7%; p = 0.011). Patients were divided into four groups according to the World Health Organization body mass index (BMI) classification and performed additional analyses. The adjusted odds ratio of hospital mortality and frailty at discharge for underweight, overweight, and obese patients relative to normal BMI was 1.25 ( p = 0.004), 0.58 ( p < 0.001), and 0.70 ( p = 0.047) and 1.53 ( p < 0.001), 0.80 ( p = 0.095), and 0.60 ( p = 0.022), respectively.

CONCLUSIONS

Obesity is associated with higher hospital survival and functional outcomes at discharge in Asian patients with sepsis.

Association of Sex Differences with Mortality and Organ Dysfunction in Patients with Sepsis and Septic Shock

BACKGROUND

Despite recent advances in the clinical management and understanding of sepsis and septic shock, these complex clinical syndromes continue to have high mortality rates. The effect of sex on these diseases' mortality, clinical presentation and morbidity remains controversial. This study aimed to investigate the association of sex with mortality and organ dysfunction in patients with sepsis and septic shock.

METHODS

Prospectively enrolled patients with clinically defined sepsis and septic shock in three intensive care units at University Medical Center Göttingen, Germany, were investigated. The primary outcomes were 28- and 90-day mortality, while the secondary endpoints included the evaluation of organ dysfunction as measured by clinical scores and laboratory parameters.

RESULTS

A total of 737 septic patients were enrolled, including 373 in septic shock, 484 males, and 253 females. No significant differences in 28- and 90-day mortality were observed in the cohort. However, men with sepsis had significantly higher SOFA scores, SOFA respiratory and renal subscores, bilirubin and creatinine values, and lower weight-adapted urine outputs, indicating higher organ dysfunction compared to women.

CONCLUSIONS

Our findings revealed notable differences in organ dysfunction between male and female patients, with males exhibiting more pronounced dysfunction across multiple clinical indicators. These results highlight the potential influence of sex on sepsis disease severity and suggest the need for tailored approaches in sepsis management according to patient sex.

Association between obesity and 1-year mortality in septic patients: a retrospective cohort study

OBJECTIVE

Sepsis is a major contributor of intensive care units (ICUs) patient mortality. Prior investigations claimed that obesity enhances overall survival (OS) of septic patients. However, the reported results were inconsistent. This study examined the association between obesity and the 1-year mortality of septic patients.

DESIGN

A retrospective cohort study.

SETTING

The Medical Information Mart for Intensive Care III database.

PARTICIPANTS

3145 septic patients were separated into three distinct cohorts, based on their WHO body mass index (BMI) status.

OUTCOMES

Our primary endpoint was the 1-year mortality from the date of ICU hospitalization.

RESULT

1334 (42.4%) died within 1 year. The 1-year mortality rate was low in obese patients (38.8%), compared with normal (46.9%) and overweight (42.1%) patients. Crude assessment revealed that obese patients experienced reduced 1-year mortality, relative to normal weight patients (HR 0.79, 95% CI 0.69 to 0.9, p<0.001). However, once adjusted for baseline variables and comorbidities, no correlation was found between obesity and the 1-year mortality (HR 0.93, 95% CI 0.81 to 1.06, p=0.28) of septic patients. There was an association among diabetic (HR 0.72, 95% CI 0.56 to 0.93, p=0.012) and hypertensive (HR 0.73, 95% CI 0.58 to 0.92, p=0.008) patients, and among males (HR 0.71, 95% CI 0.59 to 0.86, p<0.001), with obese individuals experiencing the lowest mortality rate. Given these evidences, the interactions between BMI and mortality in diabetic (p=0.031) and hypertensive (p=0.035) patients were significant.

CONCLUSION

In our study, obese diabetic and hypertensive patients associated to less sepsis-related mortality risk, compared with normal weight patients. Further researches were need to validated.

Associations of body mass index, fasting insulin, and inflammation with mortality: a prospective cohort study

BACKGROUND/OBJECTIVES

Obesity is often considered to increase the risk for premature mortality. Higher fasting insulin and c-reactive protein are associated with higher body mass index (BMI) and all-cause mortality, so may confound the association between obesity and mortality. Our objective was to determine the independent associations between BMI, fasting insulin, c-reactive protein, and all-cause mortality in a general population sample.

METHODS

This prospective cohort study included non-institutionalized US adults (≥20 years) from the National Health and Nutrition Examination Surveys 1999-2000 to 2013-2014. The main exposures of interest were BMI, fasting insulin, c-reactive protein. Mortality data were obtained through linking participants to the National Death Index (ending December 31, 2015).

RESULTS

There were 12,563 participants with a median age of 45 years (range 20-85) and 47.9% were male. The median BMI was 27 kg/m² (IQR 24-32), median fasting insulin was 54 pmol/L (IQR 35-87), and median c-reactive protein was 1.9 mg/L (IQR 0.8-4.4). In a Cox model adjusted for age, biological sex, cigarette smoking, and ten chronic conditions, higher BMI parameterized with quadratic and linear terms was not associated with mortality. When fasting insulin and the natural logarithm of c-reactive protein were included in the model, an inverse association between BMI and mortality was present (compared to the referent category of 5th percentile: 1st percentile, HR 1.10, 95% CI 1.06-1.13; 99th percentile, HR 0.48, 95% CI 0.34-0.69). In contrast, higher levels of fasting insulin and c-reactive protein were associated with an increased risk of mortality (for fasting insulin: 1st percentile, HR 0.98, 95% CI 0.97-0.99; 99th percentile, HR 1.83, 95% CI 1.48-2.26; for c-reactive protein, 1st percentile, HR 0.87, 95% CI 0.84-0.90; 99th percentile, HR 2.77, 95% CI 2.12-3.62).

CONCLUSIONS

Higher fasting insulin and higher c-reactive protein confound the association between BMI and the risk of all-cause mortality. The increase in mortality that has been attributed to higher BMI is more likely due to hyperinsulinemia and inflammation rather than obesity.

A nomogram to predict prolonged stay of obesity patients with sepsis in ICU: Relevancy for predictive, personalized, preventive, and participatory healthcare strategies

Objective

In an era of increasingly expensive intensive care costs, it is essential to evaluate early whether the length of stay (LOS) in the intensive care unit (ICU) of obesity patients with sepsis will be prolonged. On the one hand, it can reduce costs; on the other hand, it can reduce nosocomial infection. Therefore, this study aimed to verify whether ICU prolonged LOS was significantly associated with poor prognosis poor in obesity patients with sepsis and develop a simple prediction model to personalize the risk of ICU prolonged LOS for obesity patients with sepsis.

Method

In total, 14,483 patients from the eICU Collaborative Research Database were randomized to the training set (3,606 patients) and validation set (1,600 patients). The potential predictors of ICU prolonged LOS among various factors were identified using logistic regression analysis. For internal and external validation, a nomogram was developed and performed.

Results

ICU prolonged LOS was defined as the third quartile of ICU LOS or more for all sepsis patients and demonstrated to be significantly associated with the mortality in ICU by logistic regression analysis. When entering the ICU, seven independent risk factors were identified: maximum white blood cell, minimum white blood cell, use of ventilation, Glasgow Coma Scale, minimum albumin, maximum respiratory rate, and minimum red blood cell distribution width. In the internal validation set, the area under the curve was 0.73, while in the external validation set, it was 0.78. The calibration curves showed that this model predicted probability due to actually observed probability. Furthermore, the decision curve analysis and clinical impact curve showed that the nomogram had a high clinical net benefit.

Conclusion

In obesity patients with sepsis, we created a novel nomogram to predict the risk of ICU prolonged LOS. This prediction model is accurate and reliable, and it can assist patients and clinicians in determining prognosis and making clinical decisions.

Effect of the Lymphocyte Activation Gene 3 Polymorphism rs951818 on Mortality and Disease Progression in Patients with Sepsis-A Prospective Genetic Association Study

(1) Background: Sepsis is a leading cause of death and a global public health problem. Accordingly, deciphering the underlying molecular mechanisms of this disease and the determinants of its morbidity and mortality is pivotal. This study examined the effect of the rs951818 SNP of the negative costimulatory lymphocyte-activation gene 3 (LAG-3) on sepsis mortality and disease severity. (2) Methods: 707 consecutive patients with sepsis were prospectively enrolled into the present study from three surgical ICUs at University Medical Center Goettingen. Both 28- and 90-day mortality were analyzed as the primary outcome, while parameters of disease severity served as secondary endpoints. (3) Results: In the Kaplan-Meier analysis LAG-3 rs951818 AA-homozygote patients showed a significantly lower 28-day mortality (17.3%) compared to carriers of the C-allele (23.7%, p = 0.0476). In addition, these patients more often received invasive mechanical ventilation (96%) during the course of disease than C-allele carriers (92%, p = 0.0466). (4) Conclusions: Genetic profiling of LAG-3 genetic variants alone or in combination with other genetic biomarkers may represent a promising approach for risk stratification of patients with sepsis. Patient-individual therapeutic targeting of immune checkpoints, such as LAG-3, may be a future component of sepsis therapy. Further detailed investigations in clinically relevant sepsis models are necessary.

TIM-3 Genetic Variants Are Associated with Altered Clinical Outcome and Susceptibility to Gram-Positive Infections in Patients with Sepsis

Background: Previous studies have reported the fundamental role of immunoregulatory proteins in the clinical phenotype and outcome of sepsis. This study investigated two functional single nucleotide polymorphisms (SNPs) of T cell immunoglobulin and mucin domain-containing protein 3 (TIM-3), which has a negative stimulatory function in the T cell immune response. Methods: Patients with sepsis (n = 712) were prospectively enrolled from three intensive care units (ICUs) at the University Medical Center Goettingen since 2012. All patients were genotyped for the TIM-3 SNPs rs1036199 and rs10515746. The primary outcome was 28-day mortality. Disease severity and microbiological findings were secondary endpoints. Results: Kaplan-Meier survival analysis demonstrated a significantly lower 28-day mortality for TIM-3 rs1036199 AA homozygous patients compared to C-allele carriers (18% vs. 27%, p = 0.0099) and TIM-3 rs10515746 CC homozygous patients compared to A-allele carriers (18% vs. 26%, p = 0.0202). The TIM-3 rs1036199 AA genotype and rs10515746 CC genotype remained significant predictors for 28-day mortality in the multivariate Cox regression analysis after adjustment for relevant confounders (adjusted hazard ratios: 0.67 and 0.70). Additionally, patients carrying the rs1036199 AA genotype presented more Gram-positive and Staphylococcus epidermidis infections, and rs10515746 CC homozygotes presented more Staphylococcus epidermidis infections. Conclusion: The studied TIM-3 genetic variants are associated with altered 28-day mortality and susceptibility to Gram-positive infections in sepsis.

Association Between Obesity and Short-And Long-Term Mortality in Patients With Acute Respiratory Distress Syndrome Based on the Berlin Definition

PURPOSE

Acute respiratory distress syndrome (ARDS) is one of the most common causes of death in intensive care units (ICU). Previous studies have reported the potential protective effect of obesity on ARDS patients. However, these findings are inconsistent, in which less was reported on long-term prognosis and diagnosed ARDS by Berlin definition. This study aimed to investigate the relationship between obesity and short-term and long-term mortality in patients with ARDS based on the Berlin Definition.

METHODS

This is a retrospective cohort study from the Medical Information Mart for Intensive Care III (MIMIC-III) database, in which all the patients were diagnosed with ARDS according to the Berlin definition. The patients were divided into four groups according to the WHO body mass index (BMI) categories. The multivariable logistic regression and Cox regression analysis were used to investigate the relationship between BMI and short-term and long-term mortality.

RESULT

A total of 2,378 patients with ARDS were enrolled in our study. In-hospital mortality was 27.92%, and 1,036 (43.57%) patients had died after 1-year follow-up. After adjusting for confounders, the in-hospital and 1-year mortality risks of obese patients were significantly lower than those of normal weight (OR 0.72, 95%CI 0.55-0.94, P=0.0168; HR 0.80, 95%CI 0.68-0.94 P=0.0084; respectively), while those mortality risks of underweight patients were higher than normal weight patients (P=0.0102, P=0.0184; respectively). The smooth curve showed that BMI, which was used as a continuous variable, was negatively correlated with in-hospital and 1-year mortality. The results were consistent after being stratified by age, gender, race, type of admission, severity of organ dysfunction, and severity of ARDS. The Kaplan-Meier survival curves showed that obese patients had significant lower 1-year mortality than normal weight patients.

CONCLUSION

We found that obesity was associated with decreased risk of short-term and long-term mortality in patients with ARDS.