Azza MOUSTAFA, Manal AM. Antonios, Amna H. HUSSAIN, Eman M. ABDELLATIF

Association of lactate/albumin ratio level to organ failure and mortality in severe sepsis in a pediatric intensive care unit in Egypt

This study aimed at investigating the lactate to albumin ratio, as a newlyintroduced biomarker of multiple organ dysfunction syndrome (MODS) andmortality compared to the classic lactate clearance in pediatric patients. Wedesigned a prospective cohort study and 155 patients with severe sepsisor septic shock admitted to a Pediatric Intensive Care Unit were included,starting from January 2016 to March 2017. The data of 119 patients whocompleted the study, were analyzed. Results revealed that lactate clearance(6h, 24h) was significantly lower and lactate/albumin ratio (0h, 6h, 24h) wassignificantly higher in patients who developed MODS and in those who passedaway. The univariate logistic regression showed that both lactate clearanceand lactate/albumin ratio were significant prognostic factors of MODS andmortality. According to the AUC, lactate/albumin ratio (0h, 6h, 24h) showedbetter discrimination of MODS development (with AUC of 0.729, 0.814, and0.819, respectively) compared to lactate clearance (6h, 24h; AUC of 0.738,and 0.672, respectively). Again the lactate/albumin ratio (0h, 6h, 24h) showedbetter discriminatory power of mortality (0.681, 0.741, and 0.856, respectively)compared to the lactate clearance (6h, 24h; 0.638 and 0.77, respectively). TheYouden Index specified a lactate/albumin ratio (0h, 6h, 24h) of 1.17, 1.07,and 1.1 to be the cut-off discriminating values, respectively. The Kaplan-Meiercurves revealed that the cumulative of survival is significantly better for thegroup of patients with a lactate/albumin ratio less than the cut-off values. Itwas concluded that lactate/albumin ratio is a better discriminator of MODSdevelopment and mortality than lactate clearance in pediatric patients withsevere sepsis or septic shock.

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Watson RS, Carcillo JA, Linde-Zwirble WT, Clermont G, Lidicker J, Angus DC. The epidemiology of severe sepsis in children in the United States. Amer J Resp Crit Care Med 2003; 167: 695-701.

Nguyen HB, Rivers EP, Knoblich BP, et al. Early lactate clearance is associated with improved outcome in severe sepsis and septic shock. Crit Care Med 2004; 32: 1637-1642.

Vincent JL, Dufaye P, Berre J, Leeman M, Degaute JP, Kahn RJ. Serial lactate determinations during circulatory shock. Crit Care Med 1983; 11: 449-451.

Jat KR, Jhamb U, Gupta VK. Serum lactate levels as the predictor of outcome in pediatric septic shock. Indian J Crit Care Med 2011; 15: 102-107.

Mikkelsen ME, Miltiades AN, Gaieski DF, et al. Serum lactate is associated with mortality in severe sepsis independent of organ failure and shock. Crit Care Med 2009; 37: 1670-1677.

Marik PE, Bellomo R. Lactate clearance as a target of therapy in sepsis: A flawed paradigm. OA Critical Care 2013; 1: 3.

Bakker J. Lost in translation: On lactate, hypotension, sepsis-induced tissue hypoperfusion, quantitative resuscitation and Surviving Sepsis Campaign bundles. Crit Care Med 2015; 43: 705-706.

Wang B, Chen G, Cao Y, Xue J, Li J, Wu Y. Correlation of lactate/albumin ratio level to organ failure and mortality in severe sepsis and septic shock. J Crit Care 2015; 30: 271-275.

Schoonjans F, Zalta A, Depuydt CE, Comhaire FH. MedCalc: A new computer program for medical statistics. Comput Methods Programs Biomed 1995; 48: 257-262.

Goldstein B, Giroir B, Randolph A; International Consensus Conference on Pediatric Sepsis. International Pediatric Sepsis Consensus Conference: Definitions for sepsis and organ dysfunction in pediatrics. Pediatr Crit Care Med 2005; 6: 2-8.

Marshall JC. The Multiple Organ Dysfunction Syndrome. In: Holzheimer RG, Mannick JA (eds). Surgical Treatment: Evidence Based and Problem Oriented. Munich: Zuckschewrdt Verlag, 2001: 780- 785.

Leteurtre S, Martinot A, Duhamel A, et al. Validation of the paediatric logistic organ dysfunction (PELOD) score: Prospective, observational, multicentre study. Lancet 2003; 362: 192-197.

Nguyen HB, Loomba M, Yang JJ, et al. Early lactate clearance is associated with biomarkers of inflammation, coagulation, apoptosis, organ dysfunction and mortality in severe sepsis and septic shock. J Inflamm (Lond) 2010; 7: 6.

Dellinger RP, Levv MM, Rhodes A, et al; Surviving Sepsis Campaign Guidelines Committee including the Pediatric Subgroup. Surviving sepsis campaign: International guidelines for management of severe sepsis and septic shock: 2012. Crit Care Med 2013; 41: 580-637.

IBM Corp. Released 2012. IBM SPSS Statistics for Windows, Version 21.0. Armonk, NY: IBM Corp

MedCalc Statistical Software version 14.8.1 (MedCalc Software bvba, Ostend, Belgium; http://www.medcalc. org;2014).

Gorgis N, Asselin JM, Fontana C, Heidersbach RS, Flori HR, Ward SL. Evaluation of the association of early elevated lactate with outcomes in children with severe sepsis or septic shock. Pediatr Emerg Care 2017. [Epub ahead of print]

Koliski A, Cat I, Giraldi DJ, Cat ML. Blood lactate concentration as prognostic marker in critically ill children. J Pediatr (Rio J) 2005; 81: 287-292.

Hatheril M, McIntyre AG, Wattie M, Murdoch IA. Early hyperlactatemia in critically ill children. Int Care Med 2000; 26: 314-318.

Saptura DK, Runtunuwu AL, Tatura S, Manoppo J, Lolombulan JH. Lactate clearance and mortality in pediatric sepsis. Paediatr Indones 2016; 56(4): 215-220.

Artero A, Zaragoza R, Camarena JJ, Sancho S, Gonzalez R, Nogueira JM. Prognostic factors of mortality in patients with community-acquired bloodstream infection with severe sepsis and septic shock. J Crit Care 2010; 25: 276-281.

Xie Q, Zhou Y, Xu Z, et al. The ratio of CRP to albumin levels predict mortality in patients with hospital-acquired acute kidney injury. BMC Nephrol 2011; 12: 30.

Choudhary R, Sitaraman S, Choudhary A. Lactate clearance as the predictor of outcome in pediatric septic shock. J Emerg Trauma Shock 2017; 10: 55-59.

Scott HF, Brou L, Deakyne SJ, Fairclough DL, Kempe A, Bajaj L. Lactate clearance and normalization and prolonged organ dysfunction in pediatric sepsis. J Pediatr 2016; 170: 149-155.e1-4.

Choi SJ, Ha EJ, Jhang WK, Park SJ. Association between the lactate/albumin ratio and mortality in pediatric septic shock patients with underlying chronic diseases: retrospective pilot study. Minerva Pediatr 2016; (in press)

Munde A, Kumar N, Beri RS, Puliyel JM. Lactate clearance as a marker of mortality in pediatric intensive care unit. Indian Pediatr 2014; 51: 565- 567.

Sterling SA, Puskarich MA, Jones AE. The effect of liver disease on lactate normalization in severe sepsis and septic shock: A cohort study. Clin Exp Emerg Med 2015; 2: 197-202.

Levraut J, Ciebiera JP, Jambou P, Ichai C, Labib Y, Grimaud D. Effect of continuous venovenous hemofiltration with dialysis on lactate clearance in critically ill patients. Crit Care Med 1997; 25: 58-62.