Epidemiology, causes, evolution and outcome in a single-center cohort of 1116 critically ill patients with hypoxic hepatitis

Abstract

Background: Hypoxic hepatitis (HH) is a type of acute hepatic injury that is histologically characterized by centrilobular liver cell necrosis and that is caused by insufficient oxygen delivery to the hepatocytes. Typical for HH is the sudden and significant increase of aspartate aminotransferase (AST) in response to cardiac, circulatory or respiratory failure. The aim of this study is to investigate its epidemiology, causes, evolution and outcome.

Methods: The screened population consisted of all adults admitted to the intensive care unit (ICU) at the Ghent University Hospital between January 1, 2007 and September 21, 2015. HH was defined as peak AST > 5 times the upper limit of normal (ULN) after exclusion of other causes of liver injury. Thirty-five variables were retrospectively collected and used in descriptive analysis, time series plots and Kaplan-Meier survival curves with multi-group log-rank tests.

Results: HH was observed in 4.0% of the ICU admissions at our center. The study cohort comprised 1116 patients. Causes of HH were cardiac failure (49.1%), septic shock (29.8%), hypovolemic shock (9.4%), acute respiratory failure (6.4%), acute on chronic respiratory failure (3.3%), pulmonary embolism (1.4%) and hyperthermia (0.5%). The 28-day mortality associated with HH was 45.0%. Mortality rates differed significantly (P = 0.007) among the causes, ranging from 33.3% in the hyperthermia subgroup to 52.9 and 56.2% in the septic shock and pulmonary embolism subgroups, respectively. The magnitude of AST increase was also significantly correlated (P < 0.001) with mortality: 33.2, 44.4 and 55.4% for peak AST 5-10× ULN, 10-20× ULN and > 20× ULN, respectively.

Conclusion: This study surpasses by far the largest cohort of critically ill patients with HH. HH is more common than previously thought with an ICU incidence of 4.0%, and it is associated with a high all-cause mortality of 45.0% at 28 days. The main causes of HH are cardiac failure and septic shock, which include more than 3/4 of all episodes. Clinicians should search actively for any underlying hemodynamic or respiratory instability even in patients with moderately increased AST levels.

Keywords: Critical care medicine; Critically ill; Epidemiology; Hypoxic hepatitis; Intensive care medicine; Ischemic hepatitis; Liver failure; Mortality; Outcome; Shock liver.

Fig. 1

Flow diagram of the exclusion criteria. AFLP acute fatty liver of pregnancy, AST aspartate aminotransferase, CK creatine kinase, e.c.i e causa ignota, HELLP hemolysis, elevated liver enzymes and low platelet count, HH hypoxic hepatitis, HIPEC hyperthermic intraperitioneal chemotherapy, ICU intensive care unit

Fig. 2

Survival curves by cause of hypoxic hepatitis. T-ASTmax is designated as the time 0. T-ASTmax time point of maximum AST value

Fig. 3

Time trend of liver tests in hypoxic hepatitis. Time trend of the median AP, ALT, AST, bilirubin, creatinine, INR and LDH levels in hypoxic hepatitis. T-ASTmax is designated as time 0. AST, ALT, LDH and AP levels are measured in U/L and are plotted using the left y-axis. Bilirubin and creatinine levels are measured in mg/dL and plotted using the right y-axis. INR has no unit, but is also plotted using the right y-axis. AP alkaline phosphatase, ALT alanine aminotransferase, AST aspartate aminotransferase, INR international normalized ratio, LDH lactate dehydrogenase

Fig. 4

a AP level range over time; b bilirubin level range over time. Evolution of the proportion of survivors and non-survivors with alkaline phosphatase (left) and bilirubin (right) levels within and outside the reference range. T-ASTmax is designated as time 0. AP alkaline phosphatase, LLN lower limit of normal, ULN upper limit of normal

Fig. 5

Time trend of liver tests in hypoxic hepatitis of the ASTmax subgroup 5-10x ULN. Time trend of the median AP, ALT, AST, bilirubin, creatinine, INR and LDH levels in hypoxic hepatitis. T-ASTmax is designated as time 0. AST, ALT, LDH and AP levels are measured in U/L and are plotted using the left y-axis. Bilirubin and creatinine levels are measured in mg/dL and plotted using the right y-axis. INR has no unit, but is also plotted using the right y-axis. AP alkaline phosphatase, ALT alanine aminotransferase, AST aspartate aminotransferase, INR international normalized ratio, LDH lactate dehydrogenase

Fig. 6

Time trend of liver tests in hypoxic hepatitis of the ASTmax subgroup 10-20x ULN. Time trend of the median AP, ALT, AST, bilirubin, creatinine, INR and LDH levels in hypoxic hepatitis. T-ASTmax is designated as time 0. AST, ALT, LDH and AP levels are measured in U/L and are plotted using the left y-axis. Bilirubin and creatinine levels are measured in mg/dL and plotted using the right y-axis. INR has no unit, but is also plotted using the right y-axis. AP alkaline phosphatase, ALT alanine aminotransferase, AST aspartate aminotransferase, INR international normalized ratio, LDH lactate dehydrogenase

Fig. 7

Time trend of liver tests in hypoxic hepatitis of the ASTmax subgroup >20x ULN. Time trend of the median AP, ALT, AST, bilirubin, creatinine, INR and LDH levels in hypoxic hepatitis. T-ASTmax is designated as time 0. AST, ALT, LDH and AP levels are measured in U/L and are plotted using the left y-axis. Bilirubin and creatinine levels are measured in mg/dL and plotted using the right y-axis. INR has no unit, but is also plotted using the right y-axis. AP alkaline phosphatase, ALT alanine aminotransferase, AST aspartate aminotransferase, INR international normalized ratio, LDH lactate dehydrogenase