The effect of strict blood glucose control on biliary sludge and cholestasis in critically ill patients.
OBJECTIVE
Cholestatic liver dysfunction and biliary sludge are common problems in critically ill patients. No specific strategies have been described to prevent cholestasis and biliary sludge in the intensive care unit (ICU). We examined liver dysfunction and biliary sludge prospectively in a large medical long-stay ICU population and hypothesized that tight glycemic control with intensive insulin therapy (IIT) reduces cholestasis and biliary sludge.


METHODS
This study was a preplanned subanalysis of 658 long-stay (at least a fifth day) ICU patients out of a large randomized controlled trial (n = 1200), studying the effects of IIT on the outcome of medical critical illness. Patients were allocated to either IIT (glycemia 80-110 mg/dl) or conventional insulin therapy (CIT) requiring insulin above a glycemia of 215 mg/dl. Different patterns of liver dysfunction were studied based on daily blood sample analysis, and biliary sludge was evaluated by ultrasonography.


RESULTS
On admission, cholestasis was present in 17% of patients (n = 649), increasing to 20% on d 10 (n = 347), whereas ischemic hepatitis decreased from 3.4% (n = 588) to less than 1% (n = 328). IIT significantly decreased biliary sludge on d 5 (50.4 vs. 66.4%, P = 0.01; n = 250). The difference did not remain significant on d 10 (57.4 vs. 66.2%, P = 0.29; n = 136). IIT also lowered the cumulative risk of cholestasis (P = 0.03).


CONCLUSIONS
Cholestatic liver dysfunction and biliary sludge are very common during prolonged critical illness but are significantly reduced by IIT.
Mesotten
Dieter
D
Department of Intensive Care Medicine, University Hospitals of the Katholieke Universiteit Leuven, B-3000 Leuven, Belgium. dieter.mesotten@med.kuleuven.be
Wauters
Joost
J
Van den Berghe
Greet
G
Wouters
Pieter J
PJ
Milants
Ilse
I
Wilmer
Alexander
A
D000368:Aged; D000465:Algorithms; D001646:Bile / Q000187:drug effects* / Q000378:metabolism; D001786:Blood Glucose / Q000187:drug effects* / Q000378:metabolism; D002779:Cholestasis / Q000453:epidemiology / Q000209:etiology / Q000378:metabolism / Q000517:prevention & control*; D016638:Critical Illness / Q000401:mortality / Q000628:therapy*; D004305:Dose-Response Relationship, Drug; D005260:Female; D006801:Humans; D007004:Hypoglycemic Agents / Q000627:therapeutic use; D007328:Insulin / Q000627:therapeutic use*; D007362:Intensive Care Units; D008107:Liver Diseases / Q000453:epidemiology / Q000517:prevention & control; D008297:Male; D008875:Middle Aged; D015995:Prevalence; D012307:Risk Factors
D001786:Blood Glucose; D007004:Hypoglycemic Agents; D007328:Insulin