Mangana Del Rio Thomas, Sacleux Sophie-Caroline, Vionnet Julien, Ichaï Philippe, Denys Alban, Schneider Antoine, Coilly Audrey, Fraga Montserrat, Wetzel Alexandre, Koerfer Joachim, Chiche Jean-Daniel, Saliba Faouzi, Moradpour Darius, Becce Fabio, Artru Florent
Division of Gastroenterology and Hepatology, Lausanne University Hospital and University of Lausanne, Lausanne, Switzerland.
Liver Intensive Care Unit, AP-HP Paul Brousse Hospital, University Paris SACLAY, INSERM Unit N°1193, Villejuif, France.
JHEP Rep. 2023 Apr 7;5(8):100758. doi: 10.1016/j.jhepr.2023.100758. eCollection 2023 Aug.
BACKGROUND & AIMS: Body composition is sex dependent and associated with an increased mortality risk in patients with cirrhosis. We evaluated whether it was also associated with short-term mortality in patients critically ill with acute-on-chronic liver failure (ACLF).
We retrospectively included all patients with cirrhosis and ACLF hospitalised in the intensive care unit (ICU) of Lausanne University Hospital between 2010 and 2019 for whom an abdominal computed tomography (CT) scan performed ±7 days from admission was available. Patients from the ICU of Paul Brousse University Hospital admitted between 2017 and 2020 served as an external cohort. All body composition parameters at the third lumbar vertebral level (L3) were quantified using a deep learning-based method.
In total, 192 patients from Lausanne were included. Median age was 62 years and 28-day survival rate was 58.2%. In males, variables independently associated with 28-day mortality on days 1 and 3 were Chronic Liver Failure Consortium (CLIF-C) ACLF-lactate and sarcopenia. In females, CLIF-C ACLF-lactate on days 1 and 3 was the only predictor of 28-day survival. We derived two scores combining sarcopenia and the CLIF-C ACLF-lactate score on days 1 and 3, with area under the receiver operating characteristic outperforming the CLIF-C ACLF-lactate score alone in male but not in female patients. Comparable results were found in the external cohort of 58 patients and supported the sex specificity of the performance of the model. Patients with sarcopenia had increased risks of invasive fungal infection and renal replacement therapy.
Sarcopenia was associated with 28-day mortality in male but not in female patients critically ill with ACLF. Although screening for sarcopenia could impact the management of male patients, further studies are needed in female cohorts to investigate whether other body composition parameters are associated with outcomes.
Body composition, easily assessed by CT, is altered in patients with cirrhosis and associated with outcome; it has never been investigated in patients critically ill with ACLF. The results of the present study, underlining the benefit of sarcopenia evaluation to improve prognosis prediction in males critically ill with ACLF, are of importance for physicians managing such patients to optimise the decision-making process toward continued treatment, liver transplantation, or limitation of care. In a wider sense, besides the number and course of organ failures, the results recall the weight of the general condition of males with ACLF at admission to ICU. In females critically ill with ACLF, in analyses limited by the sample size, none of the body composition parameters was associated with short-term mortality independently of organ failures; this suggests that the number and course of organ failures are the main determinant of mortality in these patients.
身体组成存在性别差异，且与肝硬化患者的死亡风险增加相关。我们评估了其是否也与急性慢性肝衰竭（ACLF）危重症患者的短期死亡率相关。
我们回顾性纳入了2010年至2019年间在洛桑大学医院重症监护病房（ICU）住院的所有肝硬化合并ACLF患者，这些患者在入院±7天内进行了腹部计算机断层扫描（CT）。2017年至2020年间在保罗·布罗斯大学医院ICU住院的患者作为外部队列。使用基于深度学习的方法对第三腰椎水平（L3）的所有身体组成参数进行量化。
总共纳入了来自洛桑的192例患者。中位年龄为62岁，28天生存率为58.2%。在男性中，第1天和第3天与28天死亡率独立相关的变量是慢性肝衰竭协会（CLIF-C）ACLF-乳酸和肌肉减少症。在女性中，第1天和第3天的CLIF-C ACLF-乳酸是28天生存的唯一预测因素。我们得出了两个将肌肉减少症与第1天和第3天的CLIF-C ACLF-乳酸评分相结合的评分，其受试者工作特征曲线下面积在男性患者中优于单独的CLIF-C ACLF-乳酸评分，但在女性患者中并非如此。在58例患者的外部队列中发现了类似结果，支持了该模型性能的性别特异性。患有肌肉减少症的患者侵袭性真菌感染和肾脏替代治疗的风险增加。
肌肉减少症与ACLF危重症男性患者的28天死亡率相关，但与女性患者无关。尽管筛查肌肉减少症可能会影响男性患者的管理，但需要在女性队列中进行进一步研究，以调查其他身体组成参数是否与预后相关。
通过CT易于评估的身体组成在肝硬化患者中发生改变并与预后相关；此前从未在ACLF危重症患者中进行过研究。本研究结果强调了评估肌肉减少症对改善ACLF危重症男性患者预后预测的益处，对于管理此类患者的医生优化关于继续治疗、肝移植或限制治疗的决策过程具有重要意义。从更广泛的意义上讲，除了器官衰竭的数量和病程外，这些结果还提醒人们注意ACLF男性患者入住ICU时总体状况的重要性。在样本量有限的分析中，对于ACLF危重症女性患者，没有任何身体组成参数独立于器官衰竭与短期死亡率相关；这表明器官衰竭的数量和病程是这些患者死亡率的主要决定因素。
