Secondary sclerosing cholangitis in patients suffering cardiogenic shock

Abstract

Aims: Cardiogenic shock (CS) patients suffer from severe organ hypoperfusion, yet the incidence of secondary sclerosing cholangitis in critically ill patients (SSC-CIP) in CS is poorly described. Given the limited evidence and severity of this syndrome, we aimed to further investigate SSC-CIP in the context of CS.

Methods and results: 24 251 total CS patients admitted between 1 January 2010 and 31 December 2023 were retrospectively screened for the diagnosis of SSC-CIP across nine German tertiary care centers. Following identification of confirmed SSC-CIP diagnosis, baseline characteristics, laboratory values, SSC-CIP-specific imaging, diagnostics, and outcomes were obtained for analysis. 35 CS patients with a diagnosis of SSC-CIP were identified, representing a prevalence of 0.14% [95% confidence interval (CI) 0.10, 0.19]. Patients were predominantly male (77.1%) with a median age of 58 years (interquartile range [IQR] 52.5, 68.0). Acute myocardial infarction (42.9%) was the most common aetiology of CS, followed by cardiac arrhythmias (20.0%). Endoscopic retrograde cholangiopancreatography (ERCP) was performed in 77.1% of cases after a median of 33 days following CS onset [IQR 24, 65], showing typical biliary casts (60.0%), intraductal filling defects (28.6%), and bile duct obliteration (20.0%). Cast removal and stent placement was performed in nearly half of ERCP procedures (45.7%). Magnetic resonance cholangiopancreatography (MRCP) was performed in 22.9% of cases and showed intraductal dilation (11.4%), lumen narrowing (17.1%), or strictures (14.3%). Median intensive care unit and hospital length of stay was 43 days [IQR 33, 66] and 58 days [IQR 33, 88], respectively. In-hospital mortality was 57.1%. One-year (65.7%) and 3-year (71.4%) mortality remained high. Two patients underwent liver transplantation after a median of 113 days [IQR 105, 122] and were alive at 3-year follow-up.

Conclusions: In this multicentre retrospective analysis in a high-risk CS cohort, SSC-CIP was a rare yet serious complication of intensive care unit stay with high in-hospital mortality. Treatment options are limited, and liver transplantation remains the only viable long-term treatment option.

Keywords: Cardiogenic shock; Hepatic dysfunction; Secondary sclerosing cholangitis.