Defining the Clinical and Biochemical Course of Ischemic Hepatitis in a Large ICU Patient Population With and Without Sepsis: 761

Introduction: Ischemic hepatitis (IH) leads to dramatic rises in AST/ALT that can be difficult to diagnose in critically-ill pts. Jaundice is an uncommon manifestation of IH alone, but is commonly seen as part of sepsis. Methods: We conducted a retrospective analysis of 38,645 ICU pts between 2001-2012 at a single center using the Multiparameter Intelligent Monitoring in Intensive Care III (MIMIC-III) database to determine the biochemical features and outcome of IH in this population. IH was defined as a rapid increase in AST/ALT to >800U/L after excluding other causes. Serial values for ALT, AST, alk phos (AP), total bilirubin (TB) and albumin were analyzed and correlated to comorbidities and hospital mortality. Results: A total of 565 ICU pts (1.4%) were diagnosed with IH over the 11 years; 58% male; median age 63 yr. Hypotension prior to diagnosis of IH was documented in only 24%, however, vasopressors were used in 63%, 75% required ventilatory support, and sepsis was identified in 56%. The timeline of the biochemical profile is given in Fig. 1. LDH was initially higher than both ALT and AST; AST was >ALT for the first 2 days then the ratio reversed in those who recovered due to the longer t1/2 of ALT. TB generally remained < 3mg/dL but was significantly higher in those with sepsis [mean 3.2mg/dL (CI 2.6-3.8) vs those without [2.5 (CI 2.18-3.0)], p =0.035. All cause mortality was 44.1%. On univariate analysis, increased age, higher SAPS-II scores, sepsis, circulatory and ventilatory support, acute kidney injury (AKI), higher AST, LDH and TB, and lower albumin values were all associated with increased mortality (p value < 0.05). After adjusting for age, gender and severity using multivariate analysis, for every 1mg increase in TB, mortality increased 7% [OR 1.07, CI 1.02-1.1, P=0.008]. For every 1000 U/L increase in peak LDH, mortality also increased 7% [OR 1.07, CI 1.01-1.2, P=0.023]. AKI was associated with a 3-fold increase [OR 2.9, CI 1.4-6.1, P=0.002] and the need for vasopressors with a 2-fold increase in mortality [OR 2.1, CI 1.1-4.1, P=0.026].Figure 1Conclusion: In a large single ICU experience, IH was identified in 1.4% using AST/ALT >800 U.L. Overall mortality was 44%, driven in large part by sepsis leading to multiorgan failure, and accounting for higher TB levels compared to those without sepsis. Higher TB and LDH levels were among the factors independently associated with increased mortality, often reflecting sepsis.