A randomized-controlled trial comparing 20% albumin to plasmalyte in patients with cirrhosis and sepsis-induced hypotension [ALPS trial]

Maiwall, Rakhi; Kumar, Abhinav; Pasupuleti, Samba Siva Rao; Hidam, Ashini; Tevethia, Harsh Vardhan; Kumar, Guresh; Sahney, Amrish; Mitra, Lalita Gouri; Sarin, Shiv Kumar

doi:10.1016/j.jhep.2022.03.043

Cited by 48 publications

(49 citation statements)

References 24 publications

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“…The choice of resuscitation fluid in patients with cirrhosis and ACLF is unclear. This issue was addressed by Maiwall et al who compared the efficacy and safety of 20% Albumin to plasmalyte in the treatment of sepsis-induced hypotension ( 49 ). In critically ill patients with cirrhosis and sepsis-induced hypotension 20% albumin restores arterial pressure more quickly but causes more pulmonary complications than plasmalyte.…”

Section: Discussionmentioning

confidence: 99%

Hepatic perfusion as a new predictor of prognosis and mortality in critical care patients with acute-on-chronic liver failure

et al. 2022

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Background and aimsLiver diseases are frequent causes of morbidity and mortality worldwide. Liver diseases can lead to cirrhosis, with the risk of acute-on-chronic liver failure (ACLF). For the detection of changes in hepatic hemodynamics, Doppler ultrasonography is a well-established method. We investigated hepatic hemodynamics via serial Doppler ultrasonography to determine the predictive value of changes in hepatic perfusion for the outcome in patients with severe liver diseases compared to established prognostic models such as the MELD (Model for End-Stage Liver Disease) or CLIF-C (Chronic Liver Failure-Consortium) ACLF score.MethodsIn this prospective cohort study, hepatic perfusion was quantified at baseline before the initiation of treatment and every third day by means of serial measurements of the hepatic artery resistance index (HARI) and the maximum portal vein velocity (PVv) using Doppler ultrasonography in 50 consecutive patients with severe liver diseases admitted to a medical intensive care unit (MICU). The recorded hemodynamic parameters were compared to the MELD score, and the CLIF-C ACLF score to analyze their utility for the prediction of the outcome of patients with severe liver diseases, liver cirrhosis, and ACLF.ResultsThe changes (delta) obtained by serial measurements of the MELD score, HARI, and PVv were analyzed through scatter plots. Bivariate correlation analysis yielded a new positive linear correlation between the delta-HARI and the delta-MELD score (r = 0.469; p < 0.001). In addition, our data revealed a new negative linear correlation between delta-PVv and the delta-MELD score (r = −0.279, p = 0.001). The leading cause of MICU mortality was acute-on-chronic liver failure (ACLF). A subgroup analysis of patients with liver cirrhosis revealed a positive linear correlation between the delta-HARI and the delta-CLIF-C-ACLF score (r = 0.252, p = 0.005). Of clinical relevance, non-survivors of ACLF exhibited a significantly higher mean value for the delta-HARI (0.010 vs. −0.005; p = 0.015) and a lower mean value for the delta-PVv (−0.7 vs. 1.9 cm/s; p = 0.037) in comparison to survivors of ACLF.ConclusionThis study shows the prognostic value of the assessment of hepatic perfusion in critical care patients with severe liver diseases by bedside Doppler ultrasound examination and its utility as an accurate predictor of the outcome in patients with ACLF. Increasing HARI and a decreasing PVv are predictors of an adverse outcome. Delta-HARI and delta-PVv are new biomarkers of prognosis and ACLF-related mortality in patients with liver diseases. Delta-HARI and delta-PVv may be helpful in guiding clinical decision-making, especially in catecholamine and fluid management.

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Section: Discussionmentioning

confidence: 99%

Hepatic perfusion as a new predictor of prognosis and mortality in critical care patients with acute-on-chronic liver failure

et al. 2022

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“…With the increasing severity of sepsis disease, a large proportion of patients have circulatory instability and require ascending agents to maintain hemodynamic stability [36][37][38] , yet the inclusion of vasopressors and mean arterial pressure were rst reported in sepsisassociated liver injury in our study. Blood lactate, an indicator of tissue perfusion, is often used to provide feedback on survival in patients with sepsis 39,40 , and some high-quality studies on the effect of lactate on mortality in SALI patients have been identi ed only in children 41,42 ; this is the rst report in adult SALI patients. Some of the other variables, such as TBIL, albumin, RDW and APTT, which are frequently used in research to predict sepsis and sepsis-associated injury 14,17,18,43,44 , are rarely mentioned in studies of sepsis-associated liver injury, especially in adult reports 15 .…”

Section: Discussionmentioning

confidence: 99%

Development of a nomogram for predicting 90-day mortality in patients with sepsis- associated liver injury: a clinical study of the MIMIC-IV database

Cui

Bao

et al. 2022

Preprint

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Background The high mortality rate in sepsis patients is related to sepsis-associated liver injury (SALI). We sought to develop an accurate forecasting nomogram to estimate individual 90-day mortality in SALI patients. Methods Data from 34329 patients were extracted from the public Medical Information Mart for Intensive Care (MIMIC-IV) database. SALI was defined by total bilirubin (TBIL) > 2 mg/dL and the occurrence of an international normalized ratio (INR) > 1.5 in the presence of sepsis. Logistic regression analysis was performed to establish a prediction model called the nomogram based on the training set (n = 727), which was subsequently subjected to internal validation. Results Multivariate logistic regression analysis showed that SALI was an independent risk factor for mortality in patients with sepsis. The Kaplan‒Meier curves for 90-day survival were different between the SALI and non-SALI groups after propensity score matching (PSM) (log rank: P < 0.001 versus P = 0.038), regardless of PSM balance. The nomogram demonstrated better discrimination than the Sequential Organ Failure Assessment (SOFA) score, Logistic Organ Dysfunction System (LODS) score, Simplified Acute Physiology II (SAPS II) score, and Albumin-Bilirubin (ALBI) score in the training and validation sets, with areas under the receiver operating characteristic curve (AUROC) of 0.778 (95% CI 0.730–0.799, P < 0.001) and 0.804 (95% CI 0.713–0.820, P < 0.001), respectively. The calibration plot showed that the nomogram was sufficiently successful to predict the probability of 90-day mortality in both groups.The DCA of the nomogram demonstrated a higher net benefit regarding clinical usefulness than SOFA, LODS, SAPSII, and ALBI scores in the two groups. Conclusions The nomogram performs exceptionally well in predicting the 90-day mortality rate in SALI patients, which can be used to assess the prognosis of patients with SALI and may assist in guiding clinical practice to enhance patient outcomes.

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“…The FRISC study, a small RCT, found higher rates of hypotension reversal in septic shock when 5% albumin was administered to patients with cirrhosis 74 . A similar trial, ALPS, found 20% albumin to result in faster hemodynamic improvement and lactate clearance when compared with plasmalyte, although 28-day survival was similar 75 . This study noted higher rates of pulmonary complications, which required close monitoring during albumin repletion.…”

Section: Accepted Manuscriptmentioning

confidence: 94%

Cirrhosis Management in the Intensive Care Unit

2023

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Patients with cirrhosis frequently require admission to the intensive care unit as complications arise in the course of their disease. These admissions are associated with high short- and long-term morbidity and mortality. Thus, understanding and characterizing complications and unique needs of patients with cirrhosis and acute-on-chronic liver failure helps providers identify appropriate level of care and evidence-based treatments. While there is no widely accepted critical care admission criteria for patients with cirrhosis, the presence of organ failure and primary or nosocomial infections are associated with particularly high in-hospital mortality. Optimal management of patients with cirrhosis in the critical care setting requires a system-based approach that acknowledges deviations from canonical pathophysiology. In this review we discuss appropriate considerations and evidence-based practices for the general care of patients with cirrhosis and critical illness.

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A randomized-controlled trial comparing 20% albumin to plasmalyte in patients with cirrhosis and sepsis-induced hypotension [ALPS trial]

Cited by 48 publications

References 24 publications

Hepatic perfusion as a new predictor of prognosis and mortality in critical care patients with acute-on-chronic liver failure

Hepatic perfusion as a new predictor of prognosis and mortality in critical care patients with acute-on-chronic liver failure

Development of a nomogram for predicting 90-day mortality in patients with sepsis- associated liver injury: a clinical study of the MIMIC-IV database

Cirrhosis Management in the Intensive Care Unit

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