Gräfe Caroline, Paal Michael, Winkels Martin, Irlbeck Michael, Liebchen Uwe, Scharf Christina
Department of Anesthesiology, LMU Hospital, Munich, Germany.
Institute of Laboratory Medicine, LMU Hospital, Munich, Germany.
Blood Purif. 2023;52(11-12):849-856. doi: 10.1159/000532059. Epub 2023 Oct 11.
Hyperbilirubinemia is often the first evidence for any kind of liver disorder and over one-third of all patients in intensive care units (ICU) show elevated bilirubin concentrations. In critically ill patients, high concentrations of serum bilirubin are correlated with a poor outcome. Therapies to lower bilirubin concentrations are often just symptomatically and their effect on the patients' outcome is hardly evaluated. Therefore, this study investigates whether the extracorporeal elimination of bilirubin with the cytokine adsorber CytoSorb® (CS) reduces mortality in patients with hyperbilirubinemia.
Patients with bilirubin concentrations >10 mg/dL at the ICU were screened for evaluation from 2018 to 2020. Patients with kidney replacement therapy and older than 18 years were included. Patients with continuously decreasing bilirubin concentrations after liver transplantation or other liver support systems (i.e., Molecular Adsorbents Recirculating System [MARS®], Advanced Organ Support [ADVOS]) were excluded. CS therapy was used in clinical routine and was indicated by the treating physicians. Statistical analysis was performed with IBM SPSS statistics utilizing a multivariate model. Primary outcome measure was the effect of CS on the 30-day mortality.
Data from 82 patients (mean Simplified Acute Physiology Score [SAPS] II: 74 points, mean bilirubin: 18 mg/dL, mean lactate: 3.7 mmol/L) were analyzed. There were no significant differences in patients with and without CS treatment. The multivariate model showed no significant effect of CS therapy (p = 0.402) on the 30-day mortality. In addition, a significant effect of bilirubin concentration (p = 0.274) or Model for End-Stage Liver Disease score (p = 0.928) on the 30-day mortality could not be shown. In contrast, lactate concentration (p = 0.001, b = 0.044) and SAPS II (p = 0.025, b = 0.008) had significant impact on 30-day mortality.
The use of CS in patients with hyperbilirubinemia did not result in a significant reduction in 30-day mortality. Randomized and controlled studies with mortality as primary outcome measure are needed in the future to justify their use.
高胆红素血症往往是任何肝脏疾病的首个迹象，重症监护病房（ICU）中超过三分之一的患者胆红素浓度升高。在危重症患者中，血清胆红素浓度高与预后不良相关。降低胆红素浓度的治疗通常只是对症治疗，其对患者预后的影响很难评估。因此，本研究调查使用细胞因子吸附器CytoSorb®（CS）进行体外胆红素清除是否能降低高胆红素血症患者的死亡率。
对2018年至2020年在ICU中胆红素浓度>10mg/dL的患者进行筛选以进行评估。纳入接受肾脏替代治疗且年龄大于18岁的患者。排除肝移植或其他肝脏支持系统（即分子吸附循环系统[MARS®]、高级器官支持[ADVOS]）后胆红素浓度持续下降的患者。CS治疗用于临床常规，由主治医生决定是否使用。使用IBM SPSS统计学软件通过多变量模型进行统计分析。主要结局指标是CS对30天死亡率的影响。
分析了82例患者的数据（简化急性生理学评分[SAPS]II均值：74分，胆红素均值：18mg/dL，乳酸均值：3.7mmol/L）。接受CS治疗和未接受CS治疗的患者之间无显著差异。多变量模型显示CS治疗对30天死亡率无显著影响（p = 0.402）。此外，未显示胆红素浓度（p = 0.274）或终末期肝病评分模型（p = 0.928）对30天死亡率有显著影响。相反，乳酸浓度（p = 0.001，b = 0.044）和SAPS II（p = 0.025，b = 0.008）对30天死亡率有显著影响。
在高胆红素血症患者中使用CS并未显著降低30天死亡率。未来需要以死亡率作为主要结局指标进行随机对照研究，以证明其使用的合理性。
