title: Unmeasured anions are associated with short-term mortality in patients with hypoxic hepatitis.
abstract: OBJECTIVE
  Hypoxic hepatitis is a common cause of hepatic impairment in critically ill patients and is an independent risk factor for mortality. An elevated level of unmeasured anions is another unfavourable prognostic marker in many disease entities. While the biochemical nature of unmeasured anions is unknown, data suggest that they may be released from the liver. Therefore, the purpose of this study was to determine whether the strong ion gap-the gold standard for estimation of unmeasured anions-is elevated and associated with outcome in patients with hypoxic hepatitis.
  
  
  METHODS
  One hundred and five consecutive patients with hypoxic hepatitis admitted to the (intensive care unit) ICU of a university hospital were prospectively included in the study and compared with 15 healthy controls.
  
  
  RESULTS
  Compared with the controls, patients with hypoxic hepatitis had an elevated strong ion gap (4.0 ± 2.6 vs. 7.8 ± 4.0 mmol/L; p = 0.0002) that contributed to metabolic acidosis. Patients dying within 5 days had a larger strong ion gap upon admission than did patients surviving beyond 5 days. The mean strong ion gap (SIG) over the course of the first 5 days after admission to the ICU was 1.3 mmol/L (0.3-2.3 mmol/L) larger in patients who died compared with patients who survived, p = 0.008. In multivariate Cox-regression, larger strong ion gaps were associated with shorter survival time. The SIG correlated positively with both AST and ALT.
  
  
  CONCLUSIONS
  Unmeasured anions are elevated in patients with hypoxic hepatitis, contribute to metabolic acidosis and are associated with mortality. The liver is a possible source of the unmeasured anions, which may represent markers of tissue damage in hypoxic hepatitis.
authors.affiliation: Department of Medicine V, Ludwig-Maximilians-University, Klinikum Grosshadern, Munich, Germany.
authors.forename: Nikolaus
authors.initials: N
authors.lastname: Kneidinger
authors.forename: Georg-Christian
authors.initials: GC
authors.lastname: Funk
authors.forename: Gregor
authors.initials: G
authors.lastname: Lindner
authors.forename: Andreas
authors.initials: A
authors.lastname: Drolz
authors.forename: Peter
authors.initials: P
authors.lastname: Schenk
authors.forename: Valentin
authors.initials: V
authors.lastname: Fuhrmann
mesh_terms: D000138:Acidosis / Q000097:blood* / Q000401:mortality*; D000838:Anions / Q000097:blood*; D001317:Austria / Q000453:epidemiology; D015415:Biomarkers; D015897:Comorbidity; D005260:Female; D006505:Hepatitis / Q000097:blood* / Q000401:mortality*; D006801:Humans; D006863:Hydrogen-Ion Concentration; D000860:Hypoxia / Q000097:blood* / Q000401:mortality*; D015994:Incidence; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012307:Risk Factors; D016019:Survival Analysis; D015996:Survival Rate
chemical_list: D000838:Anions; D015415:Biomarkers