Dynamic assessments of hepatic encephalopathy and ammonia levels predict mortality in acute-on-chronic liver failure,Hepatology International

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Dynamic assessments of hepatic encephalopathy and ammonia levels predict mortality in acute-on-chronic liver failure
Hepatology International ( IF 6.6 ) Pub Date : 2021-07-18 , DOI: 10.1007/s12072-021-10221-7
Nipun Verma ₁ , Radha Krishan Dhiman ₂ , Ashok Choudhury ₃ , Sunil Taneja ₁ , Ajay Duseja ₁ , Virender Singh ₁ , Mamun Al Mahtab ₄ , Harshad Devarbhavi ₅ , Akash Shukla ₆ , Q Ning ₇ , Saeed Sadiq Hamid ₈ , Amna Shubhan Butt ₈ , Wasim Jafri ₈ , Soek Siam Tan ₉ , Jinhua Hu ₁₀ , Duan Zhongping ₁₁ , Sombat Treeprasertsuk ₁₂ , Guan H Lee ₁₃ , Hasmik Ghazinyan ₁₄ , Laurentius A Lesmana ₁₅ , Ajit Sood ₁₆ , Vandana Midha ₁₆ , Omesh Goyal ₁₆ , Dong Joon Kim ₁₇ , C E Eapen ₁₈ , Ashish Goel ₁₈ , Han Tao ₁₉ , Xin Shaojie ₂₀ , Nan Yuemin ₂₁ , A Kadir Dokmeci ₂₂ , Manoj Sahu ₂₃ , Ayaskanta Singh ₂₃ , Anil Arora ₂₄ , Ashish Kumar ₂₄ , Ramesh Kumar ₂₅ , V G Mohan Prasad ₂₆ , Ananta Shresta ₂₇ , Jose Sollano ₂₈ , Diana Alcantara Payawal ₂₉ , Samir Shah ₃₀ , P N Rao ₃₁ , Anand Kulkarni ₃₁ , George K Lau ₃₂ , Shiv Kumar Sarin ₃ ,

Affiliation

Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India.
Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India.
Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh.
Department of Hepatology, St John Medical College, Bangalore, India.
Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital, and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India.
Institute and Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China.
Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan.
Department of Medicine, Hospital Selayang, Bata Caves, Selangor, Malaysia.
Department of Medicine, 302 Military Hospital, Beijing, China.
Translational Hepatology Institute Capital Medical University, Beijing You'an Hospital, Beijing, China.
Department of Medicine, Chulalongkorn University, Bangkok, Thailand.
Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore.
Department of Hepatology, Nork Clinical Hospital of Infectious Disease, Yerevan, Armenia.
Digestive Disease and GI Oncology Centre, Medistra Hospital, Jakarta, Indonesia.
Department of Gastroenterology, DMC, Ludhiana, India.
Department of Internal Medicine, Hallym University College of Medicine, Seoul, South Korea.
Department of Hepatology, CMC, Vellore, India.
Department of Hepatology and Gastroenterology, The Third Central Clinical College of Tianjin Medical University, No. 83, Jintang Road, Hedong District, Tianjin, 300170, China.
Liver Failure Treatment and Research Center, The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, China.
Department of Traditional and Western Medical Hepatology, Third Hospital of Hebei Medical University, Shijiazhuang, China.
Department of Medicine, Ankara University School of Medicine, Ankara, Turkey.
Department of Gastroenterology and Hepatology Sciences, IMS and SUM Hospital, Bhubaneswar, Odisha, India.
Institute of Liver Gastroenterology and Pancreatico Biliary Sciences, Sir Ganga Ram Hospital, New Delhi, India.
Department of Gastroenterology, All India Institute of Medical Sciences, Patna, Bihar, India.
Department of Gastroenterology, VGM Hospital, Coimbatore, India.
Department of Hepatology, Foundation Nepal Sitapaila Height, Kathmandu, Nepal, India.
Department of Medicine, Cardinal Santos Medical Center, Manila, Philippines.
Fatima University Medical Center Manila, Manila, Philippines.
Global Hospitals, Mumbai, India.
Asian Institute of Gastroenterology, Hyderabad, India.
Department of Medicine, Humanity, and Health Medical Group, Hong Kong, People's Republic of China.

Background

We evaluated the dynamics of hepatic encephalopathy (HE) and ammonia estimation in acute-on-chronic liver failure (ACLF) patients due to a paucity of evidence.

Methods

ACLF patients recruited from the APASL-ACLF Research Consortium (AARC) were followed up till 30 days, death or transplantation, whichever earlier. Clinical details, including dynamic grades of HE and laboratory data, including ammonia levels, were serially noted.

Results

Of the 3009 ACLF patients, 1315 (43.7%) had HE at presentation; grades I–II in 981 (74.6%) and grades III–IV in 334 (25.4%) patients. The independent predictors of HE at baseline were higher age, systemic inflammatory response, elevated ammonia levels, serum protein, sepsis and MELD score (p < 0.05; each). The progressive course of HE was noted in 10.0% of patients without HE and 8.2% of patients with HE at baseline, respectively. Independent predictors of progressive course of HE were AARC score (≥ 9) and ammonia levels (≥ 85 μmol/L) (p < 0.05; each) at baseline. A final grade of HE was achieved within 7 days in 70% of patients and those with final grades III–IV had the worst survival (8.9%). Ammonia levels were a significant predictor of HE occurrence, higher HE grades and 30-day mortality (p < 0.05; each). The dynamic increase in the ammonia levels over 7 days could predict nonsurvivors and progression of HE (p < 0.05; each). Ammonia, HE grade, SIRS, bilirubin, INR, creatinine, lactate and age were the independent predictors of 30-day mortality in ACLF patients.

Conclusions

HE in ACLF is common and is associated with systemic inflammation, poor liver functions and high disease severity. Ammonia levels are associated with the presence, severity, progression of HE and mortality in ACLF patients.

中文翻译：

肝性脑病和氨水平的动态评估预测急性慢性肝衰竭的死亡率

背景

由于缺乏证据，我们评估了急性慢性肝衰竭 (ACLF) 患者的肝性脑病 (HE) 和氨评估的动态。

方法

从 APASL-ACLF 研究联盟 (AARC) 招募的 ACLF 患者随访至 30 天，死亡或移植，以较早者为准。临床细节，包括 HE 的动态等级和实验室数据，包括氨水平，被连续记录。

结果

在 3009 名 ACLF 患者中，1315 名 (43.7%) 就诊时患有 HE；981 (74.6%) 名患者的 I-II 级和 334 (25.4%) 名患者的 III-IV 级。基线 HE 的独立预测因子是较高的年龄、全身炎症反应、氨水平升高、血清蛋白、败血症和 MELD 评分（p < 0.05；各）。在基线时分别有 10.0% 的无 HE 患者和 8.2% 的 HE 患者出现 HE 的进展过程。HE 进展过程的独立预测因子是 AARC 评分（≥ 9）和氨水平（≥ 85 μmol/L）（p < 0.05; 每个）在基线。70% 的患者在 7 天内达到最终 HE 等级，最终 III-IV 级患者的生存率最差 (8.9%)。氨水平是 HE 发生、较高 HE 等级和 30 天死亡率的重要预测因子（p < 0.05；各）。7 天内氨水平的动态增加可以预测非幸存者和 HE 的进展（p < 0.05；每个）。氨、HE 分级、SIRS、胆红素、INR、肌酐、乳酸和年龄是 ACLF 患者 30 天死亡率的独立预测因子。