Transfusion with Cryoprecipitate for Very Low Fibrinogen Levels Does Not Affect Bleeding or Survival in Critically Ill Cirrhosis Patients

BACKGROUND

 Fibrinogen (FIB) levels less than 150 mg/dL have been associated with increased rates of bleeding and lower survival in critically ill cirrhosis patients.

OBJECTIVE

 We aimed to determine if treatment with cryoprecipitate (CRYO) for low FIB levels is associated with bleeding outcomes or survival.

METHODS

 A total of 237 cirrhosis patients admitted to an intensive care unit at a tertiary care liver transplant center with initial FIB levels less than 150 mg/dL were retrospectively assessed for CRYO transfusion, bleeding events, and survival outcomes.

RESULTS

 The mean MELD score was 27.2 (95% confidence interval [CI]: 26.0-28.3) and CLIF-C acute on chronic liver failure score was 53.4 (51.9-54.8). Ninety-nine (41.8%) were admitted for acute bleeding and the remainder were admitted for nonbleeding illnesses. FIB level on admission correlated strongly with disease severity. After adjusting for disease severity, FIB on admission was not an independent predictor of 30-day survival (hazard ratio [HR]: 0.99, 95% CI: 0.99-1.01, p = 0.68). CRYO transfusion increased FIB levels but had no independent effect on mortality or bleeding complications (HR: 1.10, 95% CI: 0.72-1.70, p = 0.65).

CONCLUSION

 In cirrhosis patients with critical illness, low FIB levels on presentation reflect severity of illness but are not independently associated with 30-day mortality. Treatment of low FIB with CRYO also does not affect survival or bleeding complications, suggesting FIB is an additional marker of severity of illness but is not itself a direct factor in the pathophysiology of bleeding in critically ill cirrhosis patients.

Cystatin C and Kidney Function Recovery in Patients Requiring Continuous KRT for Acute Kidney Injury

Key Points

Plasma cystatin C is decreased in participants with AKI requiring continuous KRT (CKRT) with early kidney function recovery. Despite being cleared by CKRT, plasma cystatin C in the first 3 days of CKRT may be a useful clinical tool to help predict the prognosis of AKI requiring CKRT.

Background

Plasma cystatin C is a reliable marker to estimate kidney function; however, it is unknown whether this remains true in patients receiving continuous KRT (CKRT). In this study, we tested the hypothesis that lower concentrations of plasma cystatin C during the first 3 days of CKRT would predict kidney function recovery.

Methods

We performed a retrospective observational study of 72 patients from a 126-patient, single-center CKRT study. We studied two a priori defined cohorts of patients without advanced CKD who had AKI requiring CKRT: (1 ) with early kidney function recovery defined as liberation from KRT within 7 days of CKRT initiation versus (2 ) with delayed kidney function recovery defined as receipt of KRT for >21 days or death while on KRT. Subsequent analysis included patients with advanced CKD and intermediate kidney function recovery (liberation between 8 and 21 days). Cystatin C was then measured on stored plasma, urine, and dialysis effluent collected before CKRT initiation and on days 1, 2, and 3 of CKRT.

Results

Plasma cystatin C was significantly lower in patients with early kidney function recovery in comparison with patients with delayed kidney function recovery on days 1 (1.79 versus 2.39 mg/L), 2 (1.91 versus 2.38 mg/L), and 3 (2.04 versus 2.67 mg/L) of CKRT. Sieving coefficient and CKRT clearance of cystatin C were similar for patients with early and delayed kidney function recovery. The lowest plasma cystatin C concentration on days 1–3 of CKRT predicted early kidney function recovery with an area under the receiver operating curve of 0.77 (P =0.002), positive likelihood ratio of 5.60 for plasma cystatin C <1.30 mg/L, and negative likelihood ratio of 0.17 for plasma cystatin C ≥1.88 mg/L.

Conclusions

Lower plasma cystatin C concentrations during the first 3 days of CKRT are associated with early kidney function recovery.