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Significant lung injury and its prognostic significance in acute liver failure
Sun, Ken1; Gottfried, Michelle2; Cardoso, Filipe3; McPhail, Mark4; Stravitz, Todd5; Lee, William6; Karvellas, Constantine7,8.
1. Department of Medicine, University of Alberta, Edmonton, Canada
2. Department of Public Health, Medical University of South Carolina, Charleston, USA.
3. Intensive Care Unit, Curry Cabral Hospital, Central Lisbon Hospital Center, Lisbon, Portugal.
4. Liver Intensive Care Unit, King's College Hospital, London, UK.
5. Division of Gastroenterology and Hepatology, Virginia Commonweath University, Richmond, USA.
6. Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, United States
7. Department of Critical Care Medicine, University of Alberta, Edmonton, Canada.
8. Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada.
Background: Respiratory failure is a concerning complication of acute liver failure (ALF), and high oxygen requirements often preclude ALF patients from undergoing liver transplantation LT. The aim of this study was to evaluate the association between significant lung injury (SLI) and important clinical outcomes (21-day survival, liver transplantation) in ALF patients.
Methods: Retrospective cohort included 947 (out of 3025) patients enrolled by the US Acute Liver Failure Study Group from January 1998 through December 2016 who were mechanically ventilated and for whom data regarding chest radiography and oxygenation (PaO2/FIO2) were available. ALF patients were stratified according to the Berlin definition as having SLI if PaO2/FIO2 was < 200 mm Hg, and controls with PaO2/FIO2 ≥ 200 mm Hg.
Results: Of 947 ALF patients included in this analysis, 370 (39%) had evidence of SLI while 577 (61%) did not (controls). ALF patients with SLI (ALF-SLI) had significantly worse oxygenation than controls on admission to study, (120 vs. 300 mm Hg p<0.001) and worse biochemical derangement reflected by median bilirubin (7.3 vs. 6.3 mg/dl, p=0.04), creatinine (2.3 vs. 1.8 mg/dl, p<0.001) and lactate (6.1 vs. 4.6 mmol/l, p=0.0008). ALF-SLI patients had higher rates of tracheal (19% vs. 14%) and blood-stream (17% vs. 11%, p < 0.005 for both) infections and were more likely to have received blood products (red cells 55% vs 43%; FFP 74% vs 66%; p< 0.009 for both) than controls. ALF -SLI patients required more non-respiratory organ support than controls (vasopressors 62% vs. 47%, renal replacement therapy 54% vs. 45%, p< 0.004 for both). ALF -SLI were also less likely to receive LT (18% vs. 25%, p=0.02) and had significantly decreased unadjusted 21-day transplant-free survival (TFS, 34% vs. 42%, p=0.006) than controls. After adjusting for significant covariates (logistic regression) including INR (Odds ratio ~ OR 0.81 per unit, p< 0.001) and bilirubin (OR 0.91 per unit, p<0.001), SLI was independently associated with decreased 21-day TFS (OR 0.68, p=0.01). C-index for the overall model was 0.76.
CONCLUSION:
In a large cohort of mechanically ventilated ALF patients, SLI is relatively common (39%) and associated with a need for increased non-respiratory organ support and higher blood product use. SLI was independently associated with decreased TFS and impeded the ability to list for LT.
Significant lung injury and its prognostic significance in acute liver failure
Sun, Ken1; Gottfried, Michelle2; Cardoso, Filipe3; McPhail, Mark4; Stravitz, Todd5; Lee, William6; Karvellas, Constantine7,8.
1. Department of Medicine, University of Alberta, Edmonton, Canada
2. Department of Public Health, Medical University of South Carolina, Charleston, USA.
3. Intensive Care Unit, Curry Cabral Hospital, Central Lisbon Hospital Center, Lisbon, Portugal.
4. Liver Intensive Care Unit, King's College Hospital, London, UK.
5. Division of Gastroenterology and Hepatology, Virginia Commonweath University, Richmond, USA.
6. Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, United States
7. Department of Critical Care Medicine, University of Alberta, Edmonton, Canada.
8. Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada.
Background: Respiratory failure is a concerning complication of acute liver failure (ALF), and high oxygen requirements often preclude ALF patients from undergoing liver transplantation LT. The aim of this study was to evaluate the association between significant lung injury (SLI) and important clinical outcomes (21-day survival, liver transplantation) in ALF patients.
Methods: Retrospective cohort included 947 (out of 3025) patients enrolled by the US Acute Liver Failure Study Group from January 1998 through December 2016 who were mechanically ventilated and for whom data regarding chest radiography and oxygenation (PaO2/FIO2) were available. ALF patients were stratified according to the Berlin definition as having SLI if PaO2/FIO2 was < 200 mm Hg, and controls with PaO2/FIO2 ≥ 200 mm Hg.
Results: Of 947 ALF patients included in this analysis, 370 (39%) had evidence of SLI while 577 (61%) did not (controls). ALF patients with SLI (ALF-SLI) had significantly worse oxygenation than controls on admission to study, (120 vs. 300 mm Hg p<0.001) and worse biochemical derangement reflected by median bilirubin (7.3 vs. 6.3 mg/dl, p=0.04), creatinine (2.3 vs. 1.8 mg/dl, p<0.001) and lactate (6.1 vs. 4.6 mmol/l, p=0.0008). ALF-SLI patients had higher rates of tracheal (19% vs. 14%) and blood-stream (17% vs. 11%, p < 0.005 for both) infections and were more likely to have received blood products (red cells 55% vs 43%; FFP 74% vs 66%; p< 0.009 for both) than controls. ALF -SLI patients required more non-respiratory organ support than controls (vasopressors 62% vs. 47%, renal replacement therapy 54% vs. 45%, p< 0.004 for both). ALF -SLI were also less likely to receive LT (18% vs. 25%, p=0.02) and had significantly decreased unadjusted 21-day transplant-free survival (TFS, 34% vs. 42%, p=0.006) than controls. After adjusting for significant covariates (logistic regression) including INR (Odds ratio ~ OR 0.81 per unit, p< 0.001) and bilirubin (OR 0.91 per unit, p<0.001), SLI was independently associated with decreased 21-day TFS (OR 0.68, p=0.01). C-index for the overall model was 0.76.
CONCLUSION:
In a large cohort of mechanically ventilated ALF patients, SLI is relatively common (39%) and associated with a need for increased non-respiratory organ support and higher blood product use. SLI was independently associated with decreased TFS and impeded the ability to list for LT.
Significant lung injury and its prognostic significance in acute liver failure
Sun, Ken1; Gottfried, Michelle2; Cardoso, Filipe3; McPhail, Mark4; Stravitz, Todd5; Lee, William6; Karvellas, Constantine7,8.
1. Department of Medicine, University of Alberta, Edmonton, Canada
2. Department of Public Health, Medical University of South Carolina, Charleston, USA.
3. Intensive Care Unit, Curry Cabral Hospital, Central Lisbon Hospital Center, Lisbon, Portugal.
4. Liver Intensive Care Unit, King's College Hospital, London, UK.
5. Division of Gastroenterology and Hepatology, Virginia Commonweath University, Richmond, USA.
6. Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, United States
7. Department of Critical Care Medicine, University of Alberta, Edmonton, Canada.
8. Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada.
Background: Respiratory failure is a concerning complication of acute liver failure (ALF), and high oxygen requirements often preclude ALF patients from undergoing liver transplantation LT. The aim of this study was to evaluate the association between significant lung injury (SLI) and important clinical outcomes (21-day survival, liver transplantation) in ALF patients.
Methods: Retrospective cohort included 947 (out of 3025) patients enrolled by the US Acute Liver Failure Study Group from January 1998 through December 2016 who were mechanically ventilated and for whom data regarding chest radiography and oxygenation (PaO2/FIO2) were available. ALF patients were stratified according to the Berlin definition as having SLI if PaO2/FIO2 was < 200 mm Hg, and controls with PaO2/FIO2 ≥ 200 mm Hg.
Results: Of 947 ALF patients included in this analysis, 370 (39%) had evidence of SLI while 577 (61%) did not (controls). ALF patients with SLI (ALF-SLI) had significantly worse oxygenation than controls on admission to study, (120 vs. 300 mm Hg p<0.001) and worse biochemical derangement reflected by median bilirubin (7.3 vs. 6.3 mg/dl, p=0.04), creatinine (2.3 vs. 1.8 mg/dl, p<0.001) and lactate (6.1 vs. 4.6 mmol/l, p=0.0008). ALF-SLI patients had higher rates of tracheal (19% vs. 14%) and blood-stream (17% vs. 11%, p < 0.005 for both) infections and were more likely to have received blood products (red cells 55% vs 43%; FFP 74% vs 66%; p< 0.009 for both) than controls. ALF -SLI patients required more non-respiratory organ support than controls (vasopressors 62% vs. 47%, renal replacement therapy 54% vs. 45%, p< 0.004 for both). ALF -SLI were also less likely to receive LT (18% vs. 25%, p=0.02) and had significantly decreased unadjusted 21-day transplant-free survival (TFS, 34% vs. 42%, p=0.006) than controls. After adjusting for significant covariates (logistic regression) including INR (Odds ratio ~ OR 0.81 per unit, p< 0.001) and bilirubin (OR 0.91 per unit, p<0.001), SLI was independently associated with decreased 21-day TFS (OR 0.68, p=0.01). C-index for the overall model was 0.76.
CONCLUSION:
In a large cohort of mechanically ventilated ALF patients, SLI is relatively common (39%) and associated with a need for increased non-respiratory organ support and higher blood product use. SLI was independently associated with decreased TFS and impeded the ability to list for LT.
Significant lung injury and its prognostic significance in acute liver failure
Sun, Ken1; Gottfried, Michelle2; Cardoso, Filipe3; McPhail, Mark4; Stravitz, Todd5; Lee, William6; Karvellas, Constantine7,8.
1. Department of Medicine, University of Alberta, Edmonton, Canada
2. Department of Public Health, Medical University of South Carolina, Charleston, USA.
3. Intensive Care Unit, Curry Cabral Hospital, Central Lisbon Hospital Center, Lisbon, Portugal.
4. Liver Intensive Care Unit, King's College Hospital, London, UK.
5. Division of Gastroenterology and Hepatology, Virginia Commonweath University, Richmond, USA.
6. Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, United States
7. Department of Critical Care Medicine, University of Alberta, Edmonton, Canada.
8. Division of Gastroenterology (Liver Unit), University of Alberta, Edmonton, Canada.
Background: Respiratory failure is a concerning complication of acute liver failure (ALF), and high oxygen requirements often preclude ALF patients from undergoing liver transplantation LT. The aim of this study was to evaluate the association between significant lung injury (SLI) and important clinical outcomes (21-day survival, liver transplantation) in ALF patients.
Methods: Retrospective cohort included 947 (out of 3025) patients enrolled by the US Acute Liver Failure Study Group from January 1998 through December 2016 who were mechanically ventilated and for whom data regarding chest radiography and oxygenation (PaO2/FIO2) were available. ALF patients were stratified according to the Berlin definition as having SLI if PaO2/FIO2 was < 200 mm Hg, and controls with PaO2/FIO2 ≥ 200 mm Hg.
Results: Of 947 ALF patients included in this analysis, 370 (39%) had evidence of SLI while 577 (61%) did not (controls). ALF patients with SLI (ALF-SLI) had significantly worse oxygenation than controls on admission to study, (120 vs. 300 mm Hg p<0.001) and worse biochemical derangement reflected by median bilirubin (7.3 vs. 6.3 mg/dl, p=0.04), creatinine (2.3 vs. 1.8 mg/dl, p<0.001) and lactate (6.1 vs. 4.6 mmol/l, p=0.0008). ALF-SLI patients had higher rates of tracheal (19% vs. 14%) and blood-stream (17% vs. 11%, p < 0.005 for both) infections and were more likely to have received blood products (red cells 55% vs 43%; FFP 74% vs 66%; p< 0.009 for both) than controls. ALF -SLI patients required more non-respiratory organ support than controls (vasopressors 62% vs. 47%, renal replacement therapy 54% vs. 45%, p< 0.004 for both). ALF -SLI were also less likely to receive LT (18% vs. 25%, p=0.02) and had significantly decreased unadjusted 21-day transplant-free survival (TFS, 34% vs. 42%, p=0.006) than controls. After adjusting for significant covariates (logistic regression) including INR (Odds ratio ~ OR 0.81 per unit, p< 0.001) and bilirubin (OR 0.91 per unit, p<0.001), SLI was independently associated with decreased 21-day TFS (OR 0.68, p=0.01). C-index for the overall model was 0.76.
CONCLUSION:
In a large cohort of mechanically ventilated ALF patients, SLI is relatively common (39%) and associated with a need for increased non-respiratory organ support and higher blood product use. SLI was independently associated with decreased TFS and impeded the ability to list for LT.
