Cirrhotic cardiomyopathy influences clinical outcomes and enhances performance of conventional risk prediction models in acute‐on‐chronic liver failure with severe sepsis

Author:

Kajal Kamal1ORCID,Premkumar Madhumita2ORCID,Izzy Manhal3,Kulkarni Anand V.4ORCID,Duseja Ajay Kumar2ORCID,Divyaveer Smita5,Loganathan Sekar1,Sihag Bhupendra6,Gupta Ankur6,Bahl Ajay6,Rathi Sahaj2ORCID,Taneja Sunil2ORCID,De Arka2ORCID,Verma Nipun2ORCID,Sharma Navneet7,Kaur Harpreet2,Zohmangaihi Deepy8ORCID,Kumar Vishesh2,Bhujade Harish9,Chaluvashetty Sreedhara B.9,Kalra Naveen9

Affiliation:

1. Departments of Anesthesia and Intensive Care Postgraduate Institute of Medical Education and Research Chandigarh India

2. Departments of Hepatology Postgraduate Institute of Medical Education and Research Chandigarh India

3. Division of Gastroenterology, Hepatology, and Nutrition Vanderbilt University Nashville Tennessee USA

4. Department of Hepatology Asian Institute of Gastroenterology Hyderabad India

5. Departments of Nephrology Postgraduate Institute of Medical Education and Research Chandigarh India

6. Departments of Cardiology Postgraduate Institute of Medical Education and Research Chandigarh India

7. Departments of Internal Medicine Postgraduate Institute of Medical Education and Research Chandigarh India

8. Departments of Biochemistry Postgraduate Institute of Medical Education and Research Chandigarh India

9. Departments of Radiodiagnosis and Interventional Radiology Postgraduate Institute of Medical Education and Research Chandigarh India

Abstract

SummaryBackgroundPoint‐of‐care echocardiography (POC‐Echo) is an essential intensive care hemodynamic monitoring tool.AimsTo assess POC‐Echo parameters [i.e., cardiac index (CI), systemic vascular resistance index (SVRI) and cirrhotic cardiomyopathy (CCM) markers] and serum biomarkers in predicting circulatory failure (need for vasopressors) and mortality in patients with acute‐on‐chronic liver failure (ACLF) having sepsis‐induced hypotension.MethodsWe performed serial POC‐Echo within 6 hours (h) of presentation and subsequently at 24, 48 and 72 h in patients with ACLF and sepsis‐induced hypotension admitted to our liver intensive care unit. Clinical data, POC‐Echo data and serum biomarkers were collected prospectively.ResultsWe enrolled 120 patients [59% men, aged 49 ± 12 years, 56% alcohol‐related disease and median MELDNa of 30 (27–32)], of whom 68 (56.6%) had circulatory failure, with overall mortality of 60%. CCM was present in 52.5%. The predictors of circulatory failure were CI (aHR −1.5; p = 0.021), N‐terminal brain natriuretic peptide (aHR −1.1; p = 0.007) and CCM markers; e′ septal mitral velocity (aHR −0.5; p = 0.039) and E/e′ ratio (aHR −1.2; p = 0.045). Reduction in CI by 20% and SVRI by 15% at 72 h predicted mortality with a sensitivity of 84% and 72%, and specificity 76% and 65%, respectively (p < 0.001). The MELD‐CCM model and CLIF‐CCM model were computed as MELDNa + 1.815 × E/e′ (septal) + 0.402 × e′ (septal) and CLIF‐C ACLF + 1.815 × E/e′ (septal) + 0.402 × e′ (septal), respectively, based on multivariable logistic regression. Both scores outperformed MELDNa (z‐score = −2.073, p = 0.038) and CLIF‐C ACLF score (z score = −2.683, p‐value = 0.007), respectively, in predicting 90‐day mortality.ConclusionPOC‐Echo measurements such as CCM markers (E/e' and e' velocity) and change in CI reliably predict circulatory failure and mortality in ACLF with severe sepsis. CCM markers significantly enhanced the CLIF‐C ACLF and MELDNa predictive performance.

Funder

Department of Health Research, India

Publisher

Wiley

Subject

Pharmacology (medical),Gastroenterology,Hepatology

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