Abstract
Ammonia is thought to be central to the pathogenesis of hepatic encephalopathy (HE), but its prognostic role in acute-on-chronic liver failure (ACLF) is still unknown. We aimed to determine the association between serum ammonia level and short-term prognosis in ACLF. Furthermore, we performed an in-depth evaluation of the independent effect of serum ammonia level on the short-term prognosis of hepatitis B virus (HBV) reactivation-induced ACLF patients. We identified 174 patients as part of prospective observational studies in patients with ACLF. Plasma ammonia levels were measured on admission, and several prognostic scores were used to determine the prognostic effect of ammonia. The 28-day patient survival was determined. Receiver operating characteristic analysis was used to identify the cut-off points for ammonia values, and multivariable analysis was performed using the Cox proportional hazard regression model. Plasma ammonia was significantly higher in nonsurvivors (83.53 ± 43.78 versus 67.13 ± 41.77 µmol/L, P = 0.013), and ACLF patients with hyperammonemia had significantly higher 28-day mortality than those without hyperammonemia. Ammonia was also closely related to ACLF grade (P < 0.001) and organ failure, including liver (P = 0.048), coagulation (P < 0.001) and brain (P < 0.001). HBV reactivation serves as the main precipitating factor in the ACLF population. Subgroup analysis showed that ammonia is also a strong prognostic factor in the HBV reactivation-induced ACLF population. Ammonia level is closely correlated with failure of other organs and is an independent risk factor for mortality in ACLF and the special population defined as HBV reactivation-related ACLF. Based on the results from our study, we measured serum ammonia in the population with ACLF, which strongly indicates their prognosis. It serves as an important biomarker and a therapeutic target.
Highlights
Ammonia is thought to be central to the pathogenesis of hepatic encephalopathy (HE), but its prognostic role in acute-on-chronic liver failure (ACLF) is still unknown
Total bilirubin (TB), direct bilirubin (DB), and prothrombin time (PT) levels were higher in nonsurvivors than in survivors (83.53 ± 43.78 μmol/L versus 67.13 ± 41.77 μmol/L, P = 0.013; 23.42 ± 8.17 versus 18.19 ± 8.66, P < 0.001; 17.11 ± 6.04 versus 12.90 ± 6.32, P < 0.001; 27.15 ± 9.10 versus 22.93 ± 4.49, P < 0.001), while thyroid stimulating hormone (TSH) and lymphocyte levels were lower in nonsurvivors than in survivors (0.68 ± 1.22 versus 1.07 ± 1.00, P = 0.023; 0.90 ± 0.59 versus 1.25 ± 1.01, P = 0.009)
EASL/AASLD clinical practice guidelines[17] state that high blood-ammonia levels do not add any diagnostic staging or prognostic value in HE patients with chronic liver disease. They state that HE cannot be diagnosed according to serum ammonia level since the ammonia level is in the normal range in some patients with clinical HE and neurological abnormalities
Summary
Ammonia is thought to be central to the pathogenesis of hepatic encephalopathy (HE), but its prognostic role in acute-on-chronic liver failure (ACLF) is still unknown. We aimed to determine the association between serum ammonia level and short-term prognosis in ACLF. We performed an in-depth evaluation of the independent effect of serum ammonia level on the short-term prognosis of hepatitis B virus (HBV) reactivation-induced ACLF patients. Ammonia level is closely correlated with failure of other organs and is an independent risk factor for mortality in ACLF and the special population defined as HBV reactivation-related ACLF. Based on the results from our study, we measured serum ammonia in the population with ACLF, which strongly indicates their prognosis. We performed an in-depth evaluation of the independent effect of serum ammonia level on the short-term prognosis of HBV reactivation-induced ACLF patients
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