Chiriac Stefan, Stanciu Carol, Cojocariu Camelia, Singeap Ana-Maria, Sfarti Catalin, Cuciureanu Tudor, Girleanu Irina, Igna Razvan Alexandru, Trifan Anca
Department of Gastroenterology, "Grigore T. Popa" University of Medicine and Pharmacy, Iasi 700115, Romania.
Institute of Gastroenterology and Hepatology, "St. Spiridon" Emergency Hospital, Iasi 700111, Romania.
World J Clin Cases. 2021 Jan 26;9(3):552-564. doi: 10.12998/wjcc.v9.i3.552.
High venous ammonia (VA) values have been proven to be a part of the mechanism of hepatic encephalopathy in patients with liver cirrhosis (LC) as well as acute hepatitis. Moreover, VA has been associated with poor prognosis and high mortality in these clinical settings. However, the role of ammonia in acute-on-chronic liver failure (ACLF) has not yet been clearly established.
To assess the role of VA in predicting the outcome of cirrhotic patients with ACLF in a tertiary care center.
We performed a retrospective observational study including consecutive patients with LC hospitalized for acute non-elective indications such as ascites, hepatic encephalopathy (HE), upper gastrointestinal bleeding, or bacterial infections that fulfilled the Asian Pacific Association for the Study of the Liver (APASL) criteria for ACLF. The study was conducted in "St. Spiridon" University Hospital, Iasi, Romania, a tertiary care center, between January 2017 and January 2019. The APASL ACLF Research Consortium (AARC) score was calculated and ACLF grade was established accordingly. West-haven classification was used for HE. Statistical analysis was performed using IBM SPSS version 22.0.
Four hundred and forty-six patients were included, aged 59 (50-65) years, 57.4% men. Child-Pugh, model for end-stage liver disease (MELD) and AARC scores were 11 (10-12), 19.13 ± 6.79, and 7 (6-8), respectively. 66.4% had ACLF grade I, 31.2% ACLF grade II, and 2.5% ACLF grade III. HE was diagnosed in 83.9%, 34% grade I, 37.2% grade II, 23.5% grade III, and 5.3% grade IV. Overall mortality was 7.8%. VA was 103 (78-148) μmol/L. Receiver operating characteristic analysis showed good accuracy for the prediction of in-hospital mortality for the AARC score [Area under the curve (AUC) = 0.886], MELD score (AUC = 0.816), VA (AUC = 0.812) and a fair accuracy for the Child-Pugh score (AUC = 0.799). Subsequently, a cut-off value for the prediction of mortality was identified for VA (152.5 μmol/L, sensitivity = 0.706, 1-specificity = 0.190). Univariate analysis found acute kidney injury, severe HE (grade III or IV), VA ≥ 152.5 μmol/L, MELD score ≥ 22.5, Child-Pugh score ≥ 12.5, and AARC score ≥ 8.5 to be associated with in-hospital mortality. Multivariate analysis identified AARC score ≥ 8.5 and venous ammonia ≥ 152 μmol/L to be independent predictors of in-hospital mortality.
VA could be used as an inexpensive predictor of in-hospital mortality in patients with ACLF. Patients with both ACLF and VA > 152.5 μmol/L have a high risk for a poor outcome.
高静脉血氨（VA）值已被证实是肝硬化（LC）患者以及急性肝炎患者肝性脑病机制的一部分。此外，在这些临床情况下，VA与预后不良和高死亡率相关。然而，氨在慢加急性肝衰竭（ACLF）中的作用尚未明确。
评估VA在三级医疗中心预测ACLF肝硬化患者预后中的作用。
我们进行了一项回顾性观察研究，纳入因腹水、肝性脑病（HE）、上消化道出血或细菌感染等急性非择期适应症住院的连续性LC患者，这些患者符合亚太肝脏研究协会（APASL）的ACLF标准。该研究于2017年1月至2019年1月在罗马尼亚雅西的三级医疗中心“圣斯皮里东”大学医院进行。计算APASL ACLF研究联盟（AARC）评分并据此确定ACLF分级。使用韦斯特黑文分类法对HE进行分级。使用IBM SPSS 22.0版进行统计分析。
纳入446例患者，年龄59（50 - 65）岁，男性占57.4%。Child-Pugh评分、终末期肝病模型（MELD）评分和AARC评分分别为11（10 - 12）、19.13±6.79和7（6 - 8）。66.4%为ACLF I级，31.2%为ACLF II级，2.5%为ACLF III级。83.9%的患者诊断为HE，其中I级占34%，II级占37.2%，III级占23.5%，IV级占5.3%。总死亡率为7.8%。VA为103（78 - 148）μmol/L。受试者工作特征分析显示，AARC评分[曲线下面积（AUC）= 0.886]、MELD评分（AUC = 0.816）、VA（AUC = 0.812）对预测院内死亡率具有良好的准确性，Child-Pugh评分的准确性一般（AUC = 0.799）。随后，确定VA预测死亡率的临界值为152.5 μmol/L（敏感性 = 0.706，1 - 特异性 = 0.190）。单因素分析发现急性肾损伤、重度HE（III级或IV级）、VA≥152.5 μmol/L、MELD评分≥22.5、Child-Pugh评分≥12.5以及AARC评分≥8.5与院内死亡率相关。多因素分析确定AARC评分≥8.5和静脉血氨≥152 μmol/L是院内死亡率的独立预测因素。
VA可作为ACLF患者院内死亡率的廉价预测指标。ACLF且VA>152.5 μmol/L的患者预后不良风险高。
