Department of Critical Care, University Medical Center Groningen, University of Groningen, PO Box 30001, 9700RB, Groningen, The Netherlands.
Crit Care. 2017 Aug 21;21(1):218. doi: 10.1186/s13054-017-1785-z.
The development of renal and liver dysfunction may be accompanied by initially subtle derangements in the gluconeogenetic function. Discrepantly low glucose levels combined with high lactate levels might indicate an impaired Cori cycle. Our objective was to examine the relation between early lactate and glucose levels with subsequent renal and liver dysfunction and hospital mortality in critically ill patients.
Over a 4-year period (2011 to 2014), all adult patients admitted to our adult 48-bed teaching hospital intensive care unit (ICU) for at least 12 h were retrospectively analyzed. Lactate and glucose were regularly measured with point-of-care analyzers in all ICU patients. Lactate and glucose measurements were collected from 6 h before to 24 h after ICU admission. Patients with fewer than four lactate/glucose measurements were excluded. Patients received insulin according to a computer-guided control algorithm that aimed at a glucose level <8.0 mmol/L. Renal dysfunction was defined as the development of acute kidney injury (AKI) within 7 days, and liver function was based on the maximal bilirubin in the 7-day period following ICU admission. Mean lactate and mean glucose were classified into quintiles and univariate and multivariate analyses were related with renal and liver dysfunction and hospital mortality. Since glucose has a known U-shaped relation with outcome, we also accounted for this.
We analyzed 92,000 blood samples from 9074 patients (63% males) with a median age of 64 years and a hospital mortality of 11%. Both lactate quintiles (≤1.0; 1.0-1.3; 1.3-1.7; 1.7-2.3; >2.3 mmol/L) and glucose quintiles (≤7.0; 7.0-7.6; 7.6-8.2; 8.2-9.0; >9.0 mmol/L) were related with outcome in univariate analysis (p < 0.001). Acute Physiology and Chronic Health Evaluation (APACHE) IV, lactate, and glucose were associated with renal and liver dysfunction in multivariate analysis (p < 0.001), with a U-shaped relationship for glucose. The combination of the highest lactate quintile with the lowest glucose quintile was associated with the highest rates of renal dysfunction, liver dysfunction, and mortality (p < 0.001) with a significant interaction between lactate and glucose (p ≤ 0.001).
Abnormal combined lactate and glucose measurements may provide an early indication of organ dysfunction. In critically ill patients a 'normal' glucose with an elevated lactate should not be considered desirable, as this combination is related with increased mortality.
肾功能和肝功能的衰竭可能伴随着糖异生功能最初的细微失调。葡萄糖水平明显降低，同时乳酸水平升高，可能提示科里循环受损。我们的目的是研究危重病患者入院后早期的乳酸和葡萄糖水平与随后的肾功能和肝功能衰竭及住院死亡率之间的关系。
在 4 年期间（2011 年至 2014 年），对我院成人 48 张病床的教学医院重症监护病房（ICU）中至少入住 12 小时的所有成年患者进行回顾性分析。所有 ICU 患者均使用床边分析器定期测量乳酸和葡萄糖。在 ICU 入院前 6 小时至入院后 24 小时内采集乳酸和葡萄糖检测值。乳酸/葡萄糖测量值少于 4 次的患者被排除在外。根据计算机指导的控制算法，患者接受胰岛素治疗，目标血糖水平＜8.0mmol/L。肾功能衰竭定义为 7 天内发生急性肾损伤（AKI），肝功能基于 ICU 入院后 7 天内的最大胆红素值。平均乳酸和平均葡萄糖分为五分位数，进行单变量和多变量分析，与肾功能和肝功能衰竭及住院死亡率相关。由于血糖与预后呈已知的 U 型关系，我们也考虑到了这一点。
我们分析了 9074 例患者（63%为男性）的 92000 份血样，患者中位年龄为 64 岁，住院死亡率为 11%。单变量分析显示，乳酸五分位数（≤1.0；1.0-1.3；1.3-1.7；1.7-2.3；>2.3mmol/L）和葡萄糖五分位数（≤7.0；7.0-7.6；7.6-8.2；8.2-9.0；>9.0mmol/L）与预后相关（p<0.001）。急性生理学和慢性健康评估（APACHE）IV、乳酸和葡萄糖与多变量分析中的肾功能和肝功能衰竭相关（p<0.001），血糖呈 U 型关系。乳酸五分位数最高与葡萄糖五分位数最低的组合与肾功能障碍、肝功能障碍和死亡率最高相关（p<0.001），并且乳酸和葡萄糖之间存在显著的交互作用（p≤0.001）。
异常的乳酸和葡萄糖联合检测可能提示早期器官功能障碍。在危重病患者中，不应认为“正常”的血糖水平伴升高的乳酸是理想的，因为这种组合与死亡率增加有关。
