Introduction
Ammonia is a known biomarker for hepatic encephalopathy and has also been suggested as a prognostic marker in compensated advanced chronic liver disease (ACLD), showing an association with increased risk of hospitalization and 1-year mortality, with superior performance compared to the Child-Pugh (CP) and MELDNa+ scores. However, its prognostic role in decompensated ACLD (D-ACLD) remains debated.
Aims & Methods
This study aimed to assess the prognostic performance of ammonia in D-ACLD.
A prospective, single-center cohort study including patients hospitalized for D-ACLD from 12/01/2022 to 12/01/2023, with a 1-year follow-up post-discharge. Daily clinical, laboratory, and imaging assessments were conducted during hospitalization, with ammonia levels measured at admission (D0) and on day 3 (D3). D-ACLD characterization included infection, hepatocellular carcinoma, portal vein thrombosis, rehospitalization, and mortality (in-hospital, 6-month, and 12-month).
Results
A total of 82 patients were included (mean age: 61.5 years), mostly with alcohol-related ACLD (53.7%). On average, each patient presented with 1.8 decompensations at D0, primarily hepatic encephalopathy (53.7%; n=44) and ascites (45.1%; n=37). Mean ammonia levels were 85.1 µmol/L (±67.0) at D0 and 64.8 µmol/L (±35.6) at D3. The in-hospital mortality rate was 19.5% (n=16). In univariate and multivariate analysis, ammonia-D0 correlated with MELDNa+-D0 and in-hospital infection (p<0.05). Ammonia-D3 correlated with infection and in-hospital mortality (p<0.05). ROC curve analysis for in-hospital infection prediction at D0 showed an AUC of 0.649 for ammonia, 0.648 for CP, and 0.59 for MELDNa+. ROC analysis for 6-month mortality prediction at D3 showed an AUC of 0.622 for ammonia, 0.468 for CP, and 0.351 for MELDNa+.
Conclusion
Ammonia has prognostic significance in D-ACLD, particularly in predicting in-hospital infection and 6-month mortality. However, its performance remains inferior to classical prognostic scores (CP, MELDNa+) for predicting other outcomes.
References
Shalimar, M. F. Sheikh, R. P. Mookerjee, B. Agarwal, S. K. Acharya, and R. Jalan, “Prognostic Role of Ammonia in Patients With Cirrhosis,” Hepatology, vol. 70, no. 3, pp. 982–994, Sep. 2019, doi: 10.1002/hep.30534.
M. Faisal Sheikh, R. P. Mookerjee, B. Agarwal, S. Kumar Acharya, and R. Jalan, “Prognostic Role of Ammonia in Patients With Cirrhosis,” Hepatology, vol. 70, no. 3, 2019, doi: 10.1002/hep.30534/suppinfo
T. H. Tranah et al., “Plasma ammonia levels predict hospitalisation with liver-related complications and mortality in clinically stable outpatients with cirrhosis,” J Hepatol, vol. 77, no. 6, pp. 1554–1563, Dec. 2022, doi: 10.1016/j.jhep.2022.07.014