Increased liver stiffness denotes hepatic dysfunction and mortality risk in critically ill non-cirrhotic patients at a medical ICU

Abstract

IntroductionHepatic dysfunction is a common finding in critically ill patients on the ICU and directly influences survival. Liver stiffness can be measured by the novel method of transient elastography (fibroscan) and is closely associated with hepatic fibrosis in patients with chronic liver disease, but also is increased in patients with acute hepatitis, acute liver failure and cholestasis. We investigated liver stiffness as a potentially useful tool for early detection of patients with hepatic deterioration and risk stratification with respect to short- and long-term mortality.MethodsWe prospectively evaluated 108 consecutive critically ill patients at our medical intensive care unit (ICU) with subsequent longitudinal liver stiffness measurements (admission, Day 3, Day 7 and weekly thereafter) during the course of ICU treatment. Outcome was followed after discharge (median observation time 237 days).ResultsLiver stiffness could be reliably measured in 71% of ICU patients at admission (65% at Day 3, 63% at Day 7). Critically ill patients (n = 108) had significantly increased liver stiffness compared to sex- and age-matched standard care patients (n = 25). ICU patients with decompensated cirrhosis showed highest liver stiffness, whereas other critical diseases (for example, sepsis) and comorbidities (for example, diabetes, obesity) did not impact stiffness values. At admission to the ICU, liver stiffness is closely related to hepatic damage (liver synthesis, cholestasis, fibrosis markers). During the course of ICU treatment, fluid overload (renal failure, volume therapy) and increased central venous pressure (mechanical ventilation, heart failure) were major factors determining liver stiffness. Liver stiffness values > 18 kilopascal (kPa) at ICU admission were associated with increased ICU and long-term mortality, even in non-cirrhotic patients.ConclusionsConsidering that liver stiffness cannot be validly measured in about 30% of ICU patients, transient elastography performed at ICU admission might be a useful tool to early identify liver dysfunction and predict mortality in critically ill patients at a medical ICU.

Value of liver elastography and abdominal ultrasound for detection of complications of allogeneic hemopoietic SCT

“…20 These findings reflect the limited feasibility of TE in patients with severe systemic disorders. 28 The use of the XL-probe may partially overcome this problem especially in cases with obesity, 21 but potential discordance between M-and XL-probes results remains an unsolved problem of this technique and may have impaired diagnostic accuracy in our study as well. 30 In contrast to TE, ARFI values of the right liver lobe did not show any diagnostic value, which may be explained by the smaller amount of tissue volume assessed by ARFI compared with TE.…”

“…8,9,26,27 These findings correspond with data of increased liver stiffness in critically ill non-cirrhotic patients. 28 Beyond that, TE could discriminate selected cases with severe complications in the later post-transplant course probably by reflecting severe acute hepatic injury in cases with liver affection 29 and cardiopulmonary distress in those without hepatic involvement. 26,28 These results are in line with previous case series that reported elevated LSM in patients with acute liver disease in the absence of advanced fibrosis.…”

“…28 Beyond that, TE could discriminate selected cases with severe complications in the later post-transplant course probably by reflecting severe acute hepatic injury in cases with liver affection 29 and cardiopulmonary distress in those without hepatic involvement. 26,28 These results are in line with previous case series that reported elevated LSM in patients with acute liver disease in the absence of advanced fibrosis. 27,29 Unfortunately, the diagnostic performance of TE was limited by a rather high number of invalid measurements, which occurred more frequently in our cohort than in biopsy-controlled studies focusing on hepatic fibrosis.…”

Virtual touch quantification (VTq) elastography for non-invasive assessment of liver disease and its complications: what the clinician needs to know

“…In decompensated cirrhotics, VTq shear velocities show a high level of correlation with widely used clinical prognostic scoring systems such as MELD, Child Pugh and Maddrey,35 36 and LSM by TE has shown correlation with a range of liver outcomes and also mortality or need for transplantation 34 37. Interestingly, a further study showed that in a cohort of ICU patients higher LSMs on admission was correlated with a significantly greater risk of mortality, even in those without liver disease 38. This raises the possibility of a wider significance of LSM in the critically ill, including situations beyond primary liver disease.…”

Assessing the liver to predict outcomes in heart transplantation

“…Liver biopsy is an invasive procedure that is unlikely to become a routine part of the pre-transplant evaluation. Novel imaging strategies to assess fibrosis, including transient elastography and diffusionweighted magnetic resonance imaging, have been validated in critically ill non-cardiac patients 16 and may help to risk stratify patients with severe heart failure. Likewise, novel biomarkers of hepatic fibrosis and apoptosis, including fibroblast growth factor-23, Toll-like receptor 4, and epitopes of hepatic cytokeratin-18, 17-19 may help target appropriate candidates for liver biopsy.…”