Significant lung injury and its prognostic significance in acute liver failure: A cohort analysis

Victor Dong, Ken Sun, Michelle Gottfried, Filipe S. Cardoso, Mark J. McPhail, R. Todd Stravitz, William M. Lee, Constantine J. Karvellas

Research output: Contribution to journalArticle

Abstract

Background and aims: Respiratory failure complicating acute liver failure (ALF) may preclude liver transplantation (LT). We evaluated the association between significant lung injury (SLI) and important clinical outcomes. Methods: Retrospective cohort study of 947 ALF patients with chest radiograph (CXR) and arterial blood gas (ABG) data enrolled in the US Acute Liver Failure Study Group (US-ALFSG) from January 1998 to December 2016. SLI was defined by moderate hypoxaemia (Berlin classification; PaO2/FiO2 < 200 mm Hg) and abnormalities on CXR. Primary outcomes were 21-day transplant-free survival (TFS) and overall survival. Results: Of 947 ALF patients, 370 (39%) had evidence of SLI. ALF patients with SLI (ALF-SLI) had significantly worse oxygenation than controls on admission (median PF ratio 120 vs 300 mm Hg, P <.0001) and higher lactate (6.1 vs 4.6 mmol/l, P =.0008). ALF-SLI patients had higher rates of tracheal (19% vs 14%) and bloodstream (17% vs 11%, P <.005 for both) infections and were more likely to receive transfusions (red cells 55% vs 43%; FFP 74% vs 66%; P <.009 for both). ALF-SLI patients were less likely to receive LT (18% vs 25%, P =.02) and had significantly decreased 21-day TFS (34% vs 42%) and overall survival (49% vs 64%, P <.007 for both). After adjusting for significant covariates (INR, bilirubin, acetaminophen aetiology), the development of SLI was independently associated with decreased 21-day TFS (OR 0.71, P =.03) in ALF patients (C-index 0.78). The incorporation of SLI improved discriminatory ability of the King's College Criteria (P =.0061) but not the ALFSG prognostic index (P =.34). Conclusion: Significant lung injury is a common complication in ALF patients that adversely affects patient outcomes.

Original languageEnglish (US)
JournalLiver International
DOIs
StateAccepted/In press - Jan 1 2019

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Acute Liver Failure
Lung Injury
Cohort Studies
Survival
Transplants
Liver Transplantation
International Normalized Ratio
Berlin
Acetaminophen
Bilirubin
Respiratory Insufficiency
Lactic Acid
Thorax
Retrospective Studies
Gases

Keywords

  • acute liver failure
  • acute lung injury
  • ALFSG index
  • prognosis

ASJC Scopus subject areas

  • Hepatology

Cite this

Dong, V., Sun, K., Gottfried, M., Cardoso, F. S., McPhail, M. J., Stravitz, R. T., ... Karvellas, C. J. (Accepted/In press). Significant lung injury and its prognostic significance in acute liver failure: A cohort analysis. Liver International. https://doi.org/10.1111/liv.14268

Significant lung injury and its prognostic significance in acute liver failure : A cohort analysis. / Dong, Victor; Sun, Ken; Gottfried, Michelle; Cardoso, Filipe S.; McPhail, Mark J.; Stravitz, R. Todd; Lee, William M.; Karvellas, Constantine J.

In: Liver International, 01.01.2019.

Research output: Contribution to journalArticle

Dong, Victor ; Sun, Ken ; Gottfried, Michelle ; Cardoso, Filipe S. ; McPhail, Mark J. ; Stravitz, R. Todd ; Lee, William M. ; Karvellas, Constantine J. / Significant lung injury and its prognostic significance in acute liver failure : A cohort analysis. In: Liver International. 2019.
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abstract = "Background and aims: Respiratory failure complicating acute liver failure (ALF) may preclude liver transplantation (LT). We evaluated the association between significant lung injury (SLI) and important clinical outcomes. Methods: Retrospective cohort study of 947 ALF patients with chest radiograph (CXR) and arterial blood gas (ABG) data enrolled in the US Acute Liver Failure Study Group (US-ALFSG) from January 1998 to December 2016. SLI was defined by moderate hypoxaemia (Berlin classification; PaO2/FiO2 < 200 mm Hg) and abnormalities on CXR. Primary outcomes were 21-day transplant-free survival (TFS) and overall survival. Results: Of 947 ALF patients, 370 (39{\%}) had evidence of SLI. ALF patients with SLI (ALF-SLI) had significantly worse oxygenation than controls on admission (median PF ratio 120 vs 300 mm Hg, P <.0001) and higher lactate (6.1 vs 4.6 mmol/l, P =.0008). ALF-SLI patients had higher rates of tracheal (19{\%} vs 14{\%}) and bloodstream (17{\%} vs 11{\%}, P <.005 for both) infections and were more likely to receive transfusions (red cells 55{\%} vs 43{\%}; FFP 74{\%} vs 66{\%}; P <.009 for both). ALF-SLI patients were less likely to receive LT (18{\%} vs 25{\%}, P =.02) and had significantly decreased 21-day TFS (34{\%} vs 42{\%}) and overall survival (49{\%} vs 64{\%}, P <.007 for both). After adjusting for significant covariates (INR, bilirubin, acetaminophen aetiology), the development of SLI was independently associated with decreased 21-day TFS (OR 0.71, P =.03) in ALF patients (C-index 0.78). The incorporation of SLI improved discriminatory ability of the King's College Criteria (P =.0061) but not the ALFSG prognostic index (P =.34). Conclusion: Significant lung injury is a common complication in ALF patients that adversely affects patient outcomes.",
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T2 - A cohort analysis

AU - Dong, Victor

AU - Sun, Ken

AU - Gottfried, Michelle

AU - Cardoso, Filipe S.

AU - McPhail, Mark J.

AU - Stravitz, R. Todd

AU - Lee, William M.

AU - Karvellas, Constantine J.

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N2 - Background and aims: Respiratory failure complicating acute liver failure (ALF) may preclude liver transplantation (LT). We evaluated the association between significant lung injury (SLI) and important clinical outcomes. Methods: Retrospective cohort study of 947 ALF patients with chest radiograph (CXR) and arterial blood gas (ABG) data enrolled in the US Acute Liver Failure Study Group (US-ALFSG) from January 1998 to December 2016. SLI was defined by moderate hypoxaemia (Berlin classification; PaO2/FiO2 < 200 mm Hg) and abnormalities on CXR. Primary outcomes were 21-day transplant-free survival (TFS) and overall survival. Results: Of 947 ALF patients, 370 (39%) had evidence of SLI. ALF patients with SLI (ALF-SLI) had significantly worse oxygenation than controls on admission (median PF ratio 120 vs 300 mm Hg, P <.0001) and higher lactate (6.1 vs 4.6 mmol/l, P =.0008). ALF-SLI patients had higher rates of tracheal (19% vs 14%) and bloodstream (17% vs 11%, P <.005 for both) infections and were more likely to receive transfusions (red cells 55% vs 43%; FFP 74% vs 66%; P <.009 for both). ALF-SLI patients were less likely to receive LT (18% vs 25%, P =.02) and had significantly decreased 21-day TFS (34% vs 42%) and overall survival (49% vs 64%, P <.007 for both). After adjusting for significant covariates (INR, bilirubin, acetaminophen aetiology), the development of SLI was independently associated with decreased 21-day TFS (OR 0.71, P =.03) in ALF patients (C-index 0.78). The incorporation of SLI improved discriminatory ability of the King's College Criteria (P =.0061) but not the ALFSG prognostic index (P =.34). Conclusion: Significant lung injury is a common complication in ALF patients that adversely affects patient outcomes.

AB - Background and aims: Respiratory failure complicating acute liver failure (ALF) may preclude liver transplantation (LT). We evaluated the association between significant lung injury (SLI) and important clinical outcomes. Methods: Retrospective cohort study of 947 ALF patients with chest radiograph (CXR) and arterial blood gas (ABG) data enrolled in the US Acute Liver Failure Study Group (US-ALFSG) from January 1998 to December 2016. SLI was defined by moderate hypoxaemia (Berlin classification; PaO2/FiO2 < 200 mm Hg) and abnormalities on CXR. Primary outcomes were 21-day transplant-free survival (TFS) and overall survival. Results: Of 947 ALF patients, 370 (39%) had evidence of SLI. ALF patients with SLI (ALF-SLI) had significantly worse oxygenation than controls on admission (median PF ratio 120 vs 300 mm Hg, P <.0001) and higher lactate (6.1 vs 4.6 mmol/l, P =.0008). ALF-SLI patients had higher rates of tracheal (19% vs 14%) and bloodstream (17% vs 11%, P <.005 for both) infections and were more likely to receive transfusions (red cells 55% vs 43%; FFP 74% vs 66%; P <.009 for both). ALF-SLI patients were less likely to receive LT (18% vs 25%, P =.02) and had significantly decreased 21-day TFS (34% vs 42%) and overall survival (49% vs 64%, P <.007 for both). After adjusting for significant covariates (INR, bilirubin, acetaminophen aetiology), the development of SLI was independently associated with decreased 21-day TFS (OR 0.71, P =.03) in ALF patients (C-index 0.78). The incorporation of SLI improved discriminatory ability of the King's College Criteria (P =.0061) but not the ALFSG prognostic index (P =.34). Conclusion: Significant lung injury is a common complication in ALF patients that adversely affects patient outcomes.

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