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Poster presentation | Open | Published:

Incidence of lung injury in acute liver failure: diagnostic role of extravascular lung water index

Introduction

Acute lung injury (ALI) was found to be a frequent complication of acute liver failure (ALF) in a previous study [1]. The associated mortality was high (89%) and severe hypoxia is a contraindication for liver transplantation (LT) in many transplant centers. We tried to study the incidence and outcome of ALI in a heterogeneous group of patients with ALF. In addition, we aimed to investigate the role of extravascular lung water index (EVLWI) measurements in diagnosis and management of ALI in liver failure.

Methods

A retrospective chart review of 40 patients with ALF fulfilling poor prognostic criteria admitted to a liver ITU over an 18-month period. ALI findings on chest X-ray (CXR) around the period of listing and perioperatively were correlated with oxygenation and ventilator parameters as well as measurements of EVLWI and the permeability index (EVLWI/intrathoracic blood volume index measured via transpulmonary thermodilution; PiCCO Pulsion, Munich, Germany).

Results

The cause of ALF was paracetamol overdose in 19 patients, NANB hepatitis in eight patients, and acute Budd–Chiari syndrome in five patients. The remaining eight patients suffered from acute hepatitis B virus infection, Wilsons disease, drug-induced liver failure and autoimmune hepatitis. Twenty-eight patients (70%) were transplanted and 24 survived to hospital discharge. Of the 12 nontransplant patients only one survived. A diagnosis compatible with ALI was found in 23%, with no difference between transplant and nontransplant patients. The median PaO2/FiO2 ratio (P/F) was 167 in ALI patients against 283 in nonlung injury patients (Mann–Whitney U test, not significant). Only two patients (5%) were taken off the transplant list due to a combination of refractory hypoxia and multiple organ failure. Transplant and nontransplant patients did not differ in terms of P/F, positive end expiratory pressure (PEEP), EVLWI or permeability index. Poor outcome was not associated with low P/F, CXR signs of ALI, high EVLWI or permeability index. Bilateral infiltrates on CXR correlated with PEEP (P = 0.004), EVLWI (P = 0.001) and permeability index (P < 0.001) but not with P/F. Focal lung infiltrates did not correlate with the above parameters. Twelve patients without CXR findings of ALI had significant impaired gas exchange P/F < 200, suggesting an extrapulmonary reason for hypoxia.

Conclusion

One-quarter of the patients with ALF in our series showed signs of ALI. Severe lung injury in the peri-transplant period was not associated with a high mortality. Hypoxia is nonspecific for the diagnosis of ALI and should not be used as a sole determinant to remove patients from the transplant list. The EVLWI and the permeability index are readily available bedside parameters for the diagnosis of ALI; however, they did not correlate with patient outcome.

References

  1. 1.

    Baudouin SV, et al.: Thorax 1995, 50: 399-402.

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Keywords

  • Acute Lung Injury
  • Autoimmune Hepatitis
  • Acute Liver Failure
  • Permeability Index
  • Transpulmonary Thermodilution