Early serum ammonia variation in critically ill patients with cirrhosis: A multicentre cohort study

Abstract

SummaryBackgroundSerum ammonia variation in critically ill patients with cirrhosis has been poorly studied.AimTo describe and assess the impact of serum ammonia variation in these patients' outcomes.MethodsWe studied patients ≥18 years old admitted to the intensive care units (ICUs) at University of Alberta Hospital (Edmonton, Canada) and Curry Cabral Hospital (Lisbon, Portugal; derivation cohort, n = 492) and Northwestern University Hospital (Chicago, USA; validation cohort, n = 600) between January 2010 and December 2021. Primary exposure was ICU days 1–3 serum ammonia. Primary endpoint was all‐cause hospital mortality.ResultsIn the derivation cohort, 330 (67.1%) patients were male and median (IQR) age was 57 (50–63) years. On ICU day 1, median ammonia was higher in patients with grade 3/4 hepatic encephalopathy (HE) than those with grade 2 HE or grade 0/1 HE (112 vs. 88 vs. 77 μmoL/L, respectively; p < 0.001). Furthermore, medium ammonia was higher in hospital non‐survivors than survivors (99 vs. 86 μmol/L; p < 0.030). Following adjustment for significant confounders (age, HE, vasopressor use and renal replacement therapy delivery), higher ICU day 2 ammonia was independently associated with higher hospital mortality (adjusted OR per each 10 μmoL/L increment [95% CI] = 1.11 [1.01–1.21]; p = 0.024). In the validation cohort, this model with serial ammonia (ICU days 1 and 3) predicted hospital mortality with reasonably good discrimination (c‐statistic = 0.73) and calibration (R2 = 0.19 and Brier score = 0.17).ConclusionsAmong patients with cirrhosis in the ICU, early serum ammonia variation was independently associated with hospital mortality. In this context, serial serum ammonia may have prognostic value.

Letter: Exploring the clinical utility of ammonia in critically ill patients with cirrhosis: More to do?

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Editors,We read with great interest the article by Cardoso et al 1 They found that serum ammonia was associated with hepatic encephalopathy (HE) severity, and that serum ammonia concentration on days 2 and 3 was associated with in-hospital mortality among critically ill patients with cirrhosis. They also developed a model with serial ammonia with good performance in predicting in-hospital mortality.In the past decades, the clinical utility of ammonia in patients with cirrhosis has been disputed.

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