Changes in thyroid function in patients with liver failure and their clinical significance: A clinical study of non-thyroidal illness syndrome in patients with liver failure.

BACKGROUND: Non-thyroidal illness syndrome (NTIS) develops in a large proportion of critically ill patients and is associated with high risk for death. We aimed to investigate the correlation between NTIS and liver failure, and the short-term mortality of patients with these conditions. METHODS: The clinical data of 87 patients with liver failure were collected retrospectively, 73 of them were randomly selected for an observational study and to establish prognostic models, and 14 for model validation. Another 73 sex- and age-matched patients with mild chronic hepatitis were randomly selected as a control group. Serum free triiodothyronine (FT3), free thyroxine (FT4), and thyroid-stimulating hormone (TSH) were measured. The clinical characteristics of patients with liver failure and NTIS were analyzed. The follow-up of patients lasted for 3 months. Additionally, the values for predicting short-term mortality of model for end-stage liver disease (MELD), Child-Turcotte-Pugh (CTP), chronic liver failure-sequential organ failure assessment (CLIF-SOFA) scores, FT3-MELD model, and FT3 were evaluated. RESULTS: The observation group had significantly lower FT3 (2.79 ± 0.71 vs. 4.43 ± 0.75 pmol/L, P < 0.001) and TSH [0.618 (0.186-1.185) vs. 1.800 (1.570-2.590) mIU/L, P < 0.001], and higher FT4 (19.51 ± 6.26 vs. 14.47 ± 2.19 pmol/L, P <0.001) than the control group. NTIS was diagnosed in 49 of the patients with liver failure (67.12%). In the observation group, patients with NTIS had a higher mortality rate than those without (63.27% vs. 25.00%, P = 0.002). Across the whole cohort, the 3-month mortality was 50.68%. The international normalized ratios (INR) were 2.40 ± 1.41 in survivors and 3.53 ± 1.81 in deaths (P = 0.004), the creatinine (Cr) concentrations were 73.27 ± 36.94 µmol/L and 117.08 ± 87.98 µmol/L (P = 0.008), the FT3 concentrations were 3.13 ± 0.59 pmol/L and 2.47 ± 0.68 pmol/L (P < 0.001), the MELD scores were 22.19 ± 6.64 and 29.57 ± 7.99 (P < 0.001), the CTP scores were 10.67 ± 1.53 and 11.78 ± 1.25 (P = 0.001), and the CLIF-SOFA scores were 8.42 ± 1.68 and 10.16 ± 2.03 (P < 0.001), respectively. FT3 was negatively correlated with MELD score (r = -0.430, P < 0.001). An FT3-MELD model was established by subjecting FT3 concentration and MELD score to logistic regression analysis using the following formula: Logit(P) = -1.337 × FT3+0.114 × MELD+0.880. The area under the receiver operating characteristic (ROC) curve was 0.827 and the optimal cut-off value was 0.4523. The corresponding sensitivity and specificity were 67.6% and 91.7%. The areas under the ROC curve for FT3 concentration, MELD score, CTP score, and CLIF-SOFA score were 0.809, 0.779, 0.699, and 0.737, respectively. CONCLUSIONS: Patients with liver failure often develop NTIS. FT3-MELD score perform better than CTP and CLIF-SOFA scores in predicting mortality in patients with liver failure. Thus, the FT3-MELD model could be of great value for the evaluation of the short-term mortality of such patients.

Indocyanine green clearance test combined with MELD score in predicting the short-term prognosis of patients with acute liver failure.

BACKGROUND: Acute liver failure (ALF) is an acute severe deterioration of liver function with high mortality. Early and accurate prognostic assessment of patients with ALF is critically important. Although the model for end-stage liver disease (MELD) scores and King's College Hospital (KCH) criteria are well-accepted as predictive tools, their accuracy is unsatisfactory. The indocyanine green (ICG) clearance test (ICGR15, ICG retention rate at the 15 minutes) is a sensitive indicator of liver function. In this study, we investigated the efficacy of the ICGR15 for the short-term prognosis in patients with ALF. We compared the predictive value of ICGR15 with the MELD scores and KCH criteria. METHODS: Sixty-nine patients who had been diagnosed with ALF were recruited retrospectively. ICGR15 had been performed by ICG pulse spectrophotometry and relevant clinical and laboratory indices were analyzed within 24 hours of diagnosis. In addition, the MELD scores and KCH criteria were calculated. RESULTS: The three-month mortality of all patients was 47.83%. Age, serum total bilirubin and creatinine concentrations, international normalized ratio for prothrombin time, ICGR15, MELD scores and KCH criteria differed significantly between surviving and deceased patients. A positive correlation was observed between ICGR15 and MELD scores (r=0.328, P=0.006). The ICGR15-MELD model, Logit(P)=0.096XICGR15+0.174XMELD score-9.346, was constructed by logistic regression analysis. The area under the receiver operating characteristic curve was 0.855. When set the cut-off point to -0.4684, the sensitivity was 87.90% and specificity, 72.20%. The area under the receiver operating characteristic curve of the ICGR15-MELD model (0.855) was significantly higher than that of the ICGR15 (0.793), MELD scores (0.776) and KCH criteria (0.659). Based on this cut-off value, the patients were divided into two groups. The mortality was 74.36% in the first group (ICGR15-MELD≥-0.4686) and 13.33% in the second group (ICGR15-MELD<-0.4686), with a significant difference between the two groups (X(2)=25.307, P=0.000). CONCLUSION: The ICGR15-MELD model is superior to the ICGR15, MELD scores, and KCH criteria in predicting the short-term prognosis of patients with ALF.

[Clinical experience of double plasma molecular absorption with a combination of two hemoperfusion machines in treatment of liver failure].

OBJECTIVE: To evaluate the effect of the double plasma molecular adsorption system (DPMAS) with a combination of two hemoperfusion machines in treatment of liver failure. METHODS: A retrospective analysis was conducted. The clinical data from 42 patients with liver failure admitted to Tianjin Second People's Hospital from September 2012 to September 2013 were enrolled. Patients received 166 courses of blood purification treatment, including 97 courses of plasmapheresis (PE) and 69 courses of DPMAS. The DPMAS treatment was performed with a combination of two hemoperfusion machines, with one a blood pump and the other a plasma pump, for 2-3 hours. Liver function, tumor necrosis factor-α (TNF-α), electrolytes and blood routine were determined before and after treatment. Adverse reactions were observed and the nursing experiences were summarized. RESULTS: The survival rate of 42 liver failure patients was 64.29%, and the total bilirubin (TBil), NH3, total bile acid (TBA) and TNF-α were decreased and the albumin (ALB) was increased after PE and DPMAS. Further analysis of the rate of changes after treatment (after treatment/before treatment×100%) showed that when compared with that in DPMAS, the TBil and TBA were decreased significantly in PE [TBil: (62.21 ± 5.51)% vs. (64.39 ± 4.61)%, t=2.683, P=0.008; TBA: (77.10 ± 4.44)% vs. (85.91 ± 6.95)%, t=9.952, P=0.000], and the level of ALB was elevated significantly in PE when compared with that in DPMAS [(113.12 ± 2.90)% vs. (101.87 ± 2.91)%, t=24.602, P=0.000]. NH3 and TNF-α were decreased in both groups withe no statistical significance [NH3: (79.59 ± 5.72)% vs. (80.56 ± 7.56)%, t=0.934, P=0.351; TNF-α: (61.66 ± 4.67)% vs. (62.73 ± 3.67)%, t=1.638, P=0.108]. The blood electrolytes and routine blood test showed that there was no significant change before and after treatments in DPMAS group (K⁺: 3.92 ± 0.83 mmol/L vs. 3.91 ± 0.82 mmol/L, t=0.501, P=0.618; Na⁺: 136.89 ± 5.69 mmol/L vs. 136.74 ± 5.83 mmol/L, t=1.077, P=0.285; Cl⁻: 96.58 ± 3.33 mmol/L vs. 96.55 ± 3.27 mmol/L, t=0.245, P=0.807; white cell count: 5.22 ± 0.93 × 109/L vs. 5.43 ± 1.11 × 109/L, t=1.125, P=0.265; hemoglobin: 110.97 ± 19.20 g/L vs. 112.69 ± 19.67 g/L, t=0.643, P=0.522; platelet count: 105.28 ± 26.82 × 109/L vs. 101.96 ± 3.08 × 109/L, t=0.727, P=0.470). Sixty-four out of the 69 courses of DPMAS treatment were successfully completed, and 5 times were ended because of line coagulation. There was no uncomfortable symptom complained by 53 patients during the treatment. Hypotension occurred for 3 times, and discomfort and nausea during treatment were complained for 9 times. Low fever occurred 4 times after treatment. Those uncomfortable symptoms were relieved spontaneously or by symptomatic treatment. Psychological nursing care should be given to the patients before and after DPMAS to relieve anxiety. Circulating tubes should be well rinsed to prevent line coagulation. General condition of the patient should be closely monitored in order to adjust therapeutic measures. CONCLUSIONS: DPMAS could be effectively performed with a combination of two hemoperfusion machines without inadvertent side reactions, and it is safe in operation with smaller amount of plasma.