Anion gap as a prognostic tool for risk stratification in critically ill patients – a systematic review and meta-analysis

Glasmacher, Stella A.; Stones, William

doi:10.1186/s12871-016-0241-y

Cited by 42 publications

(40 citation statements)

References 38 publications

(64 reference statements)

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“…AG has been proved to be associated with prognosis of many cardiovascular diseases [10][11][12][13][14]. A meta-analysis proved that AG was strongly related to mortality in critically ill patients [15]. Moreover, AG was confirmed to be associated with higher blood pressure [16], insulin resistance [17], and cardiorespiratory fitness [18].…”

Section: Introductionmentioning

confidence: 99%

Anion Gap Was Associated with Inhospital Mortality and Adverse Clinical Outcomes of Coronary Care Unit Patients

Sun

Cai

Shen

et al. 2020

BioMed Research International

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Background. Anion gap (AG) has been proved to be associated with prognosis of many cardiovascular diseases. This study is aimed at exploring the association of AG with inhospital all-cause mortality and adverse clinical outcomes in coronary care unit (CCU) patients. Method. All data of this study was extracted from Medical Information Mart for Intensive Care III (MIMIC-III, version 1.4) database. All patients were divided into four groups according to AG quartiles. Primary outcome was inhospital all-cause mortality. Lowess smoothing curve was drawn to describe the overall trend of inhospital mortality. Binary logistic regression analysis was performed to determine the independent effect of AG on inhospital mortality. Result. A total of 3593 patients were enrolled in this study. In unadjusted model, as AG quartiles increased, inhospital mortality increased significantly, OR increased stepwise from quartile 2 (OR, 95% CI: 1.01, 0.74-1.38, P=0.958) to quartile 4 (OR, 95% CI: 2.72, 2.08-3.55, P<0.001). After adjusting for possible confounding variables, this association was attenuated, but still remained statistically significant (quartile 1 vs. quartile 4: OR, 95% CI: 1.02, 0.72-1.45 vs. 1.49, 1.07-2.09, P=0.019). Moreover, CCU mortality (P<0.001) and rate of acute kidney injury (P<0.001) were proved to be higher in the highest AG quartiles. Length of CCU (P<0.001) and hospital stay (P<0.001) prolonged significantly in higher AG quartiles. Maximum sequential organ failure assessment score (SOFA) (P<0.001) and simplified acute physiology score II (SAPSII) (P<0.001) increased significantly as AG quartiles increased. Moderate predictive ability of AG on inhospital (AUC: 0.6291), CCU mortality (AUC: 0.6355), and acute kidney injury (AUC: 0.6096) was confirmed. The interactions were proved to be significant in hypercholesterolemia, congestive heart failure, chronic lung disease, respiratory failure, oral anticoagulants, Beta-blocks, angiotensin-converting enzyme inhibitor (ACEI)/angiotensin receptor blocker (ARB), and vasopressin treatment subgroups. Conclusion. AG was an independent risk factor of inhospital all-cause mortality and was associated with adverse clinical outcomes in CCU patients.

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Section: Introductionmentioning

confidence: 99%

Anion Gap Was Associated with Inhospital Mortality and Adverse Clinical Outcomes of Coronary Care Unit Patients

Sun

Cai

Shen

et al. 2020

BioMed Research International

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“…Only a single AG or BE measurement may interfere with therapeutic interventions that can affect the patients’ conditions and underlying diseases. 28 …”

Section: Discussionmentioning

confidence: 99%

Can base excess and anion gap predict lactate level in diagnosis of septic shock?

Pongmanee¹,

Vattanavanit

2017

OAEM

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BackgroundLactate measurement is the key component in septic shock identification and resuscitation. However, point-of-care lactate testing is not widely used due to the lack of access to nearby test equipment. Biomarkers such as serum lactate, anion gap (AG), and base excess (BE) are used in determining shock in patients with seemingly normal vital signs.PurposeWe aimed to determine if these biomarkers can be used interchangeably in patients with septic shock in the emergency setting.Patients and methodsA prospective observational cohort study was undertaken at a tertiary hospital in southern Thailand. Baseline point-of-care BE, AG, and serum lactate were recorded in all patients presenting with septic shock at the emergency department. Overall correlations including area under the receiver operating characteristic curve (AUROC) for both BE and AG to predict serum lactate level were calculated.ResultsOne hundred and fifteen patients were enrolled. Pearson correlation of serum lactate to BE was −0.59 (r2 = 0.35; 95% confidence interval [CI], −0.69 to −0.44; P < 0.001) and BE to AG was −0.67 (r2 = 0.49; 95% CI, −0.76 to −0.55; P < 0.001), and serum lactate to AG was 0.64 (r2 = 0.41; 95% CI, 0.52 to 0.74; P < 0.001). A cut-off point of 15.8 for AG identified a lactate level ≥2 mmol/L (sensitivity, 71.4%; specificity, 80.7%; and AUROC, 0.76), and the best cut-off value to predict a lactate level ≥4 mmol/L was 18.5 (sensitivity, 64.2%; specificity, 85.5%; and AUROC 0.78).ConclusionIn patients with septic shock, lactate and AG showed a strong correlation with each other, whereas lactate and BE showed a moderate correlation with each other. Thus, these biomarkers can be used interchangeably to help determine septic shock earlier in patients.

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“…Studies were excluded if the blood samples for AG and lactate were drawn more than 2 h apart. The search strategy, study selection and data extraction processes are described in our previous review [ 3 ] although in the current review no restriction on publication date was applied. Methodological quality was rated independently by two reviewers using a modified version of the Quality Assessment of Diagnostic Accuracy Studies (QUADAS-2) tool [ 5 ].…”

Section: Main Textmentioning

confidence: 99%

“…Overall, the studies included in the present review are of higher quality than those included in our previous review, in which we investigated the ability of the AG to predict 31-day or in-hospital mortality [ 3 ]. The main reason may be that fewer variables need to be accounted for to establish the relationship between AG and lactate whereas mortality is affected by multiple factors, which can be difficult to control for.…”

Section: Main Textmentioning

confidence: 99%

“…Our present review was intended to add confirmatory evidence to determine whether, in low-resource settings, efforts should be focused on making the best use of available resources to measure AG, or to widen access to lactate analysis. In a previous systematic review and meta-analysis, [ 3 ] we determined that the AG does not predict 31-day mortality, in-hospital mortality and comparable outcome measures. However, the findings of the previous review were limited by the poor methodological quality of included studies and significant statistical heterogeneity in meta-analysis.…”

Section: Introductionmentioning

confidence: 99%

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A systematic review and diagnostic test accuracy meta-analysis of the validity of anion gap as a screening tool for hyperlactatemia

Glasmacher

Stones

2017

BMC Res Notes

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ObjectiveThis systematic review and meta-analysis seeks to determine the validity of the anion gap to screen for hyperlactatemia in critically ill patients. We have previously shown that the anion gap does not predict 31-day and in-hospital mortality in critically ill patients. The present review aims to add confirmatory evidence to identify whether the anion gap is a suitable tool for risk stratification in low-resource countries.ResultsNine studies reporting on 4504 samples from 2111 patients were included. The anion gap failed to detect hyperlactatemia defined as lactate above 2.5 mmol/l but showed good discriminatory ability for the detection of severe hyperlactatemia defined as lactate over 4 mmol/l. At the 2.5 mmol/l threshold, the anion gap had high specificity but low sensitivity for the detection of hyperlactatemia. A meta-analysis of correlation coefficients yielded high statistical heterogeneity. Therefore, in keeping with our previous findings, the use of the anion gap for risk stratification as an alternative to lactate cannot be recommended. However, the strength of the evidence we have synthesised is adversely affected by the small number of studies included, inconsistency of effect measures and positivity thresholds reported, and selection bias within individual studies. PROSPERO Registration Number: CRD42015016470 (registered on the 4th February 2015).Electronic supplementary materialThe online version of this article (10.1186/s13104-017-2853-9) contains supplementary material, which is available to authorized users.

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Anion gap as a prognostic tool for risk stratification in critically ill patients – a systematic review and meta-analysis

Cited by 42 publications

References 38 publications

Anion Gap Was Associated with Inhospital Mortality and Adverse Clinical Outcomes of Coronary Care Unit Patients

Anion Gap Was Associated with Inhospital Mortality and Adverse Clinical Outcomes of Coronary Care Unit Patients

Can base excess and anion gap predict lactate level in diagnosis of septic shock?

A systematic review and diagnostic test accuracy meta-analysis of the validity of anion gap as a screening tool for hyperlactatemia

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