Can sarcopenia predict poor prognosis of sepsis due to biliary sepsis?

doi:10.21203/rs.3.rs-3420593/v1

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Can sarcopenia predict poor prognosis of sepsis due to biliary sepsis?

https://doi.org/10.21203/rs.3.rs-3420593/v1

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published 22 Jan, 2024

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Aim of the study:

Sepsis is a life-threatening disease, contributing to significant morbidity and mortality. This study aimed to investigate the association between sarcopenia and the prognosis of patients with biliary sepsis, focusing on outcomes such as length of hospital stay (LOS), intensive care unit (ICU) admission, and in-hospital mortality.

Methods

This retrospective, single-center, observational study included adult patients with biliary sepsis who visited the emergency department between January 2016 and December 2021. Sarcopenia was assessed using the psoas muscle index (PMI). Using computed tomography imaging, the area of both sides of the psoas muscle at the L3 level was measured, and the PMI, corrected by the patient’s height was calculated. The primary outcome was in-hospital mortality, and the secondary outcomes were intensive care unit (ICU) admission, LOS, and 14-day mortality.

Results

A total of 745 patients were included in this study. Sarcopenia was defined as a PMI < 421 mm²/m² for males and < 268 mm²/m² for females with the lower quartile of PMI according to sex. The cohort was classified into sarcopenic (n = 189) and non-sarcopenic (n = 556) groups. There was a significant association between sarcopenia and in-hospital mortality (odds ratio, 3.81; 95% confidence interval, 1.08–13.47), while there was no significant association between sarcopenia and ICU admission. In addition, the median LOS in the sarcopenic group (10 [7–14] days) was significantly longer than the median (8 [6–11] days) in the non-sarcopenic group.

Conclusions

Sarcopenia was significantly associated with clinical outcomes, particularly in-hospital mortality and LOS, in patients with biliary sepsis.

Biological sciences/Immunology/Infection

Biological sciences/Immunology/Infectious diseases

Health sciences/Medical research

Health sciences/Risk factors

Sarcopenia

Psoas muscle

Biliary sepsis

Sepsis

Prediction model

Although sarcopenia lacks a precise definition, it is generally recognized as an age-related loss of skeletal muscle mass.¹ While aging is the primary factor associated with sarcopenia, other factors such as chronic inflammatory conditions (e.g., malignant tumors, cardiovascular and pulmonary disease, and inflammatory conditions) can also contribute to its development. ^2,3 Acute sarcopenia can also occur in acute inflammatory conditions, such as sepsis, leading to rapid muscle loss. ⁴ Although research on muscle mass loss in acute severe illness is limited compared to that in chronic conditions, studies suggest that skeletal muscle plays a crucial role in physical recovery, rehabilitation, and long-term functionality after hospitalization. ⁵

Various methods are available to measure muscle mass loss. One such method is grip strength, which is measured using a calibrated portable dynamometer. Accurate measurement involves interpreting the data based on population norms. ⁶ Another method is the chair stand test, which evaluates leg muscle strength and endurance by measuring the time taken to perform five consecutive chair stands without using the arms. ^5,7,8 Anthropometry is occasionally used to reflect nutritional status in the elderly but is not suitable for precise muscle mass measurement. However, calf circumference measurement can serve as a diagnostic tool when other methods are not available. ⁹

Using CT or MRI is one of good options to measure muscle mass loss. However, the measurement of all muscles in the body using CT or MRI is limited. Previous studies have investigated whether specific muscles proportionally reflect overall muscle mass. ^10–12

Shen et al. reported a linear relationship (R² = 0.86) between the total skeletal muscle area from whole-body MRI and the skeletal muscle mass from a 5 cm CT cross-sectional image above the L4-5 intervertebral disc. ¹¹ They also found a linear relationship between psoas muscle cross-sectional area on CT and whole-body skeletal muscle mass. ^{10 11} Particularly, the psoas muscle, which is less affected by exercise, was found to better reflect sarcopenia compared to appendicular muscles that respond to exercise. ^13–15

Sepsis affects nearly 50 million people worldwide annually and contributes to over 11 million deaths, despite access to high-quality medical services. ¹⁶ Sepsis, severe sepsis, and septic shock are common conditions seen in emergency rooms and ICUs, with mortality rates ranging between 30–60% despite appropriate treatment. ^17–19 The prognosis of patients with sepsis is significantly influenced by early recognition and the prompt initiation of appropriate therapy. ²⁰ Therefore, early recognition and appropriate treatment in the emergency room can significantly affect patient prognosis. ²¹

Physiological scoring systems, such as the Sequential Organ Failure Assessment (SOFA) score, are commonly used to evaluate sepsis severity and predict prognosis. However, these scoring systems focus solely on the physiological status and do not consider frailty in elderly patients. Incorporating frailty assessment alongside physiological status may improve prognostic accuracy. ^22–25 Studies have explored the relationship between sarcopenia and the prognosis of sepsis. However, considering sepsis as a single disease is challenging, because its prognosis varies depending on the underlying cause. ²⁶ Hence, our study aimed to investigate the association between sarcopenia and prognosis in a specific disease with a uniform prognosis. Although a recent study analyzed sarcopenia and prognosis in acute cholecystitis-induced sepsis, clinical practice often involves additional conditions, such as common bile duct or intrahepatic duct involvement. Therefore, our study aimed to explore the association between sarcopenia and the prognosis of biliary sepsis.

Study design and population

This retrospective, observational study was conducted at a tertiary university hospital in Bucheon, South Korea. The study protocol was approved by the Institutional Review Board of Soonchunhyang University Bucheon Hospital (IRB file no. 2022-12-010). The IRB waived the requirement for informed consent because the study involved the analysis of a pre-existing data, so informed consent was not obtained from each patient. This study had been performed in accordance with the Declaration of Helsinki. This study included patients presented emergency department between January 2016 and December 2021. Patients with biliary sepsis who visited the emergency department during the study period were included. Sepsis was idefitied when a patient exhibited a Sequential Organ Failure Assessment (SOFA) score of 2 or more, accompanied by clinical indication of infection.²⁷ Patients under 18 years of age, those who were discharged or died within 24 hours, those who did not undergo CT, those with a Do Not Resuscitate (DNR) status, those with Discharge Against Medical Advice (DAMA), those transferred to another hospital, and those with other final diagnoses were excluded.²⁷ The conclusive diagnosis was ascertained through a combination of medical documentation and the radiologist’s analysis of the CT findings.²⁷ Sepsis due to biliary cause and other diseases were classified accordingly.

Variables

Data including age, sex, medical comorbidities, and initial vital signs were collected from the medical records of the enrolled patients. Initial laboratory test results, including arterial blood gas, complete blood count, and serum chemistry, were also collected. Records of procedures or surgeries performed to treat the cause of biliary sepsis and their clinical outcomes were documented. To determine the severity of sepsis, the SOFA and Quick Sequential Organ Failure Assessment (qSOFA) scores were calculated.²⁷ The primary outcome was in-hospital mortality, and secondary outcomes included intensive care unit (ICU) admission, length of hospital stay (LOS), and 14-day mortality.²⁷

Measurement on CT imaging

Abdominal CT scan images were used to assess the psoas muscle area. Consistent with previous studies, cross-sectional images at the level of the L3 transverse process were selected.^28–31 Researchers, who were blinded to patient information, traced the psoas muscle margins using an area assessment software to calculate the total psoas area (TPA) (Fig. 1).²⁷ The TPA was normalized to the individual’s height to obtain the psoas muscle index (PMI): PMI = Total psoas muscle area at the L3 level/height² (mm²/m²).²⁷

Definition of sarcopenia

In previous studies, if the muscle area values of the cohort were normally distributed, the mean minus two standard deviations (mean-2SD) was used as the cut-off value for sarcopenia.^32–38 If the muscle area values were not normally distributed, the lowest quartile was used as the cut-off value.^32–38 In this study, given the non-normal distribution of muscle area values, the cut-off for sarcopenia was set at the lower quartile, with a PMI < 421 mm²/m² for men and < 268 mm²/m² for women (Fig. 2).

Statistical analysis

All statistical analyses were performed using the R software version 4.0.3 for Windows (R Foundation for Statistical Computing, Vienna, Austria). Utilizing the established PMI threshold, patients were categorized into either the sarcopenic or non-sarcopenic cohorts. Categorical variables are denoted by counts and proportions, while continuous ones that don't follow a normal distribution are indicated by median values and their interquartile ranges (IQR). To contrast these variables, the study used the Chi-square or Fisher's exact test and the Wilcoxon rank-sum test, adopting a significance criterion of p < 0.05. To discern factors independently influencing clinical results, logistic regression was used. Variables deemed significant for the logistic regression were chosen through a univariate analysis, which assessed the association between clinical outcomes and dependent factors. To evaluate the predictive power of the logistic model against SOFA and qSOFA scores, Receiver Operating Characteristic (ROC) curves were drawn.

Between January 2016 and December 2021, 2,489 patients with biliary sepsis presented to the ED. Of this cohort, patients with SOFA score less than 2 (n = 1,417) were precluded from the study. After screening the remaining 1,072 patients, the following exclusions were made: those below 18 years of age (n = 1), fatalities within the first 24 hours (n = 1), patients who had undergone CT (n = 2), patients with directives of DNR or DAMA (n = 44), inter-hospital transfer (n = 10), and those with differential final diagnoses (n = 269). Consequently, 745 patients were deemed eligible and included in the final analysis (Fig. 3).

In this cohort, cut-off values for sarcopenia corresponding to the lowest quartile were set as PMI < 421 mm²/m² for men and < 268 mm²/m² for women (Fig. 2).

Patients were classified into a non-sarcopenic group (n = 556) and a sarcopenic group (n = 189). The baseline characteristics of each group are shown in Table 1. The sarcopenic group was significantly older than the non-sarcopenic group (median 77.0 vs. median 68.0 years) and had a significantly lower median body mass index (median 21.2 vs. median 24.3 kg/m²).

When comparing non-sarcopenic and sarcopenic groups, the proportion of comorbidities, including diabetes, heart failure, liver cirrhosis, and malignant neoplasia, was significantly higher in the sarcopenic group. In terms of initial vital signs, the sarcopenic group had significantly lower median mean arterial pressure (MAP) (median 93.3 vs. 96.7 mmHg) and O₂ saturation (96.0 vs. 97.0%). In laboratory tests, the sarcopenic group had significantly higher levels of blood urea nitrogen (BUN) (20.6 vs. 16.2 mg/dL), C-reactive protein (CRP) (8.1 vs. 4.7 mg/dL), and lactate (2.7 vs. 1.8 mg/dL), but significantly lower levels of albumin (3.6 vs. 4.0 g/dL). Further, the sarcopenic group had a significantly higher SOFA score (median 3, IQR 2–5 vs. 3, 2–4). The proportion of qSOFA scores in the sarcopenic group was less than 2 points in 88.9% of patients and 2 points or more in 20.1%, whereas in the non-sarcopenic group, it was 95.8% and 4.2%, respectively.

There were significant differences in ICU admission, LOS, in-hospital mortality, 14-day mortality, inotropic agent use in the ER, and intubation in the ER between the sarcopenic and non-sarcopenic groups. The sarcopenic group had significantly higher rates of ICU admissions (26.5 vs. 11.2%), LOS (8 vs. 10 day), use of inotropic agents (11.6 vs. 4.7%), emergency intubation (4.2 vs. 0.4%), in-hospital mortality (5.8 vs. 0.7%), and 14-day mortality (3.4 vs. 0.6%).

Sarcopenia was a predictor of in-hospital mortality after biliary sepsis (Table 2) but was not a predictor of ICU admission. In the multivariate logistic model for predicting in-hospital mortality, albumin (OR, 0.34; 95% CI, 0.12-1.00), sarcopenia (OR, 3.81; 95% CI, 1.08–13.47), and BUN (OR, 1.03; 95% CI, 1.01–1.06) were independent prognostic indicators (Table 2). In the multivariate logistic model for predicting ICU admission, BUN (OR, 1.02; 95% CI, 1.00-1.03, albumin (OR, 0.40; 95% CI, 0.26–0.61), MAP (OR, 0.97; 95% CI, 0.95–0.98), and saturation (OR, 0.91; 95% CI, 0.86–0.97) were independent prognostic indicators (Table 2). In the logistic model, which predicted in-hospital mortality with MAP, BUN, and sarcopenia, albumin demonstrated the highest predictive power as a result of comparison with SOFA score and qSOFA score using the ROC curve (area under the curve of the logistic model vs. SOFA vs. qSOFA was 0.91 vs. 0.78 vs. 0.74) (Fig. 4).

In the subgroup analysis, the sarcopenic group had a significantly higher ICU admission rate than the non-sarcopenic group (30.8 vs. 13.5%, p = 0.03) and a significantly higher in-hospital mortality rate (12.8 vs. 1%, p = 0.01) in the antibiotic use group; however, this difference was not statistically significant. In the percutaneous drainage-only group, the ICU admission rate was higher in the non-sarcopenic group than in the sarcopenic group; however, there was no significant difference in mortality rates between the groups. There was no significant difference in in-hospital mortality according to the detailed treatment plan (percutaneous drainage vs. ERCP vs. surgery, or percutaneous drainage after ERCP surgery) (Table 3).

This study aimed to investigate the effect of sarcopenia on the prognosis of patients with biliary sepsis, including LOS, ICU admission, and in-hospital mortality. Our findings indicate that sarcopenia is a valuable predictor of these prognoses, particularly for predicting in-hospital mortality using logistic models, which demonstrated the highest predictive power.

We conducted a subgroup analysis to explore the association between sarcopenia and clinical outcomes in different treatment groups, including conservative treatment, ERCP only, ERCP combined with other treatments, percutaneous drainage, and surgery. The results revealed that in-hospital mortality was significantly higher in the sarcopenic group than in the non-sarcopenic group in the conservative treatment group (1 vs. 12.8%, p = 0.01), whereas invasive treatments (ERCP, percutaneous drainage, and surgery) had minimal impact on mortality. Additionally, in the conservative treatment group, the rate of ICU admission was significantly higher in the sarcopenic group (30.8%) than in the non-sarcopenic group (13.5%) (p = 0.03). However, there was no significant difference in in-hospital mortality between the groups that underwent invasive treatment. These findings suggest that sarcopenia is associated with an increased likelihood of in-hospital mortality. However, invasive treatments mitigate this risk in patients with sarcopenia.

Previous studies have reported similar results regarding the association between sarcopenia and the prognosis of sepsis. Oh et al. found a correlation between sarcopenia and short-term (28-days) and long-term (1 year and overall) mortality in 905 patients with septic shock. ⁶

In addition, Cox et al. investigated the results of pre-existing muscle atrophy and acute muscle loss. Muscle mass changes were measured by analyzing CT scans of critically ill patients with intra-abdominal sepsis at 3-month and 12-month intervals. After diagnosing intra-abdominal sepsis in critically ill patients, muscle mass continued to decrease acutely. While there was a correlation between reduced quality of life and physical function for three months after sepsis, pre-existing muscle atrophy was independently associated with poor long-term functional status and increased one-year mortality. ⁵

Okada et al. developed a "modified SOFA score" by adding sarcopenia to the SOFA score and evaluated its predictive performance. This study included 255 patients with various causes of sepsis admitted to the ICU and compared the 90-day mortality rates. This study revealed an association between psoas sarcopenia detected on CT and 90-day mortality. ⁷

The relationship between sarcopenia and the prognosis of various diseases can be attributed to the central role of skeletal muscles in amino acid metabolism and immune responses under stressful conditions, such as sepsis. ³⁹ In our study, the sarcopenia group had significantly lower serum albumin levels, which is consistent with the findings of a meta-analysis that reported lower serum albumin levels in patients with sarcopenia. ⁴⁰ However, it remains unclear whether providing nutrients such as amino acids or protein supplements can improve disease prognosis.

According to Kim et al., patients diagnosed with acalculous cholecystitis (AAC) were divided into surgical and non-surgical groups, and their outcomes were compared. Patients who underwent open or laparoscopic cholecystectomy at AAC onset were classified into the surgical group, whereas those who underwent percutaneous transhepatic gallbladder drainage (PTGBD) with or without intravenous antibiotics were classified into the non-surgical group. The average length of hospital stay did not differ significantly between the two groups; however, the incidence of treatment-related complications was significantly higher in the surgical group (18.8 vs. 2.4%, p = 0.02). There was no significant difference in the recurrence rate between the percutaneous drainage-only and antibiotic-only groups in the non-surgical group (3.7 vs. 4.60%, p = 0.26), and there were no deaths related to recurrence in either group. The treatment outcomes in the non-surgical group were not inferior to those in the surgical group. This finding differs from that of our subgroup analysis, which indicated that invasive treatment mitigates the negative impact of sarcopenia. The difference may be attributed to the inclusion criteria of our study, which focused on severe patients with SOFA scores of 2 or higher and biliary sepsis, while Kim's study included patients with a wider range of conditions and only acute cholecystitis.

When examining mortality rates according to severity in the Tokyo Guidelines 13, it can be inferred that our study yielded different results because of the significant inclusion of mild cases in the population. The observed mortality rates were mild (Grade I) (1/161, 0.6%), moderate (Grade II) (0/60, 0%), and severe (Grade III) (3/14, 21.4%). ⁹

Another study investigated the association between mortality and antibiotic choice in ICU patients with severe acute cholangitis. This study found no significant differences in mortality rates between patients treated with amoxicillin and clavulanate and those treated with ceftriaxone and metronidazole. This study also compared different gallbladder decompression techniques (endoscopic, surgical, and percutaneous) and found no significant differences in mortality. ⁴¹ These findings are consistent with our grouping of patients who underwent invasive treatments for comparative purposes.

Our study has several strengths. First, unlike previous studies, we focused on the prognosis of sepsis resulting from a specific infection focus, rather than on the overall prognosis of sepsis with diverse mechanisms and infection foci. Sepsis has various mechanisms of action and different infection foci, which cannot be grouped into a single category for studying the relationship between sarcopenia and sepsis prognosis because the causative bacteria can differ, and mortality rates may inevitably vary depending on the cause. Therefore, it is necessary to study prognosis according to the infection site rather than the relationship between sarcopenia and the overall sepsis prognosis. Our study has significant strengths in comparing the prognosis of sepsis resulting from sarcopenia and biliary tract-related infection. Second, we performed a subgroup analysis by dividing the patients into groups based on their treatment approach, which provided deeper insights into the impact of sarcopenia on prognosis. Although statistically significant differences were found in both ICU admission and in-hospital mortality between the nonsarcopenic and sarcopenic groups treated with only antibiotics, there was no statistically significant difference in in-hospital mortality between the groups that underwent percutaneous drainage, ERCP, or surgery. In the group that underwent percutaneous drainage or ERCP as a single treatment, the sarcopenia group was more likely to be admitted to the ICU than the conservative treatment group using antibiotics alone. However, when examining 14-day mortality and in-hospital mortality, no significant differences were observed in prognosis, suggesting that this was compensated for. Thus, in biliary sepsis, sarcopenia affects the prognosis of mortality and ICU admission in the conservative treatment group using antibiotics alone; however, in the group that received aggressive treatment, sarcopenia did not have a significant impact on prognosis. Therefore, it can be concluded that invasive treatment compensates for the poor prognosis caused by sarcopenia. Finally, the risk of selection bias in our study was minimal as most patients with biliary sepsis who visited the hospital underwent abdominal CT imaging for a differential diagnosis.

However, this study has some limitations. First, the diagnosis of sarcopenia was based solely on the investigation of skeletal muscle mass at the third lumbar vertebra using CT. Physical performance and muscle strength assessments were not conducted because of the retrospective nature of the study. Second, it was difficult to determine a significant relationship between mortality and prognosis because the cohort had a low mortality rate of 6.5% (15/745). In a study by Bauer, the 30-day septic shock mortality rate was 33.7% (95% CI, 31.5–35.9) in North America, 32.5% (95% CI, 31.7–33.3) in Europe, and 26.4% (95% CI, 18.1–34.6) in Australia. ⁸ However, the Tokyo Guidelines suggest a mortality rate of approximately 2.7–10% for acute cholecystitis and cholangitis and approximately 1% for severe grade III disease. ⁹ The mortality rate for biliary sepsis, including cholangitis and cholecystitis in our study, was approximately 3.7–11.0%, which included a rate of 6.5% in our study. ¹⁰ Third, the results of the study can vary depending on the cut-off value used to define sarcopenia, and a consensus on the cut-off value for sarcopenia needs to be established. Statistics on sarcopenia in Asians are insufficient, and further studies are required to establish sarcopenia indices for various nationalities and races to investigate the relationship between sarcopenia and disease prognosis. Fourth, only SOFA and qSOFA scores were used to assess the severity of biliary sepsis. However, the lactate level, APACHE II score, and SAPS II score can also be used to determine the severity of sepsis. As we were limited by the retrospective nature of our study, we could not collect such data and apply these scores. Fifth, ICU admission, which was one of the outcomes of our study, was subjectively determined by emergency physicians and gastroenterologists because there were no clear criteria for ICU admission at our hospital. Sixth, the treatment plan for biliary sepsis was subjectively determined by the clinicians, which may have influenced the patient's prognosis. Finally, our study had a small sample size and was a single-center study. Further studies are needed to resolve these limitations and provide strong evidence.

Sarcopenia was significantly associated with in-hospital mortality and length of hospitalization in patients with biliary sepsis. Based on these results, earlier and more effective treatments should be considered for patients with sarcopenia and biliary sepsis. Further studies are warranted to overcome the limitations of this study and provide robust evidence in this field.

Acknowledgement

The contents are solely the responsibility of the authors.

Funding statement

This work was supported by the Soonchunhyang University research fund.

Conflict of interest statement

The authors declare no conflicts of interest.

Data availability

The datasets used and/or analysed during the current study available from the corresponding author on reasonable request.

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Table 1

Comparison of general demographics and clinical variables between sarcopenic and non-sarcopenic patients
Variables	Non-Sarcopenic (N = 556)	Sarcopenic (N = 189)	P
Age, years (median, IQR)	68.0 (55.0–78.0)	77.0 (66.0–83.0)	< 0.001
Gender, male	318 (57.2%)	107 (56.6%)	0.957
BMI, kg/m² (median, IQR)	24.3 (22.3–26.8)	21.2 (19.2–23.7)	< 0.001
Comorbidities (N, %)
Hypertension	270 (48.7)	101 (53.7)	0.273
Diabetes mellitus	157 (28.2)	71 (37.6)	0.021
Heart failure	20 (3.6)	17 (9.0)	0.006
COPD	13 (2.3)	4 (2.1)	1.000
Liver cirrhosis	15 (2.7)	12 (6.3)	0.037
CKD	56 (10.1)	18 (9.6)	0.950
CVA	60 (10.8)	30 (15.9)	0.085
Neoplasm	62 (11.2)	39 (20.6)	0.002
Initial vital signs (median, IQR)
SBP, mmHg	130.0 (116.5–150.0)	120.0 (105.0–140.0)	< 0.001
DBP, mmHg	80.0 (70.0–90.0)	80.0 (64.0–90.0)	0.039
MAP, mmHg	96.7 (86.7–110.0)	93.3 (80.0–106.7)	0.003
HR, beats/min	89.0 (77.0–100.0)	92.0 (80.0–107.0)	0.037
RR, breaths/mm	20.0 (18.0–20.0)	20.0 (20.0–20.0)	0.187
BT, ˚C	37.2 (36.7–38.0)	37.3 (36.6–38.2)	0.610
O₂ saturation, %	97.0 (95.0–98.0)	96.0 (94.0–98.0)	< 0.001
Laboratory findings (median, IQR)
WBC, *1000	10.3 (7.5–14.5)	11.7 (8.0–16.0)	0.017
Platelets, *1000	186.5 (136.0–239.5)	165.0 (124.0–229.0)	0.044
Albumin, g/dL	4.0 (3.6–4.3)	3.6 (3.1–4.0)	< 0.001
BUN, mg/dL	16.2 (11.9–21.8)	20.6 (13.6–31.5)	< 0.001
Creatinine, mg/dL	1.1 (0.9–1.4]	1.1 (0.8–1.6)	0.400
Total bilirubin, mg/dL	2.5 (1.6–4.5)	2.4 (1.3–4.0)	0.132
CRP, mg/dL	4.7 (0.8–13.1)	8.1 (3.8–16.7)	< 0.001
SOFA score (median, IQR)	3.0 (2.0–4.0)	3.0 (2.0–5.0)	< 0.001
qSOFA score (N, %)			< 0.001
0	425 (76.4)	104 (55.0)
1	108 (19.4)	64 (33.9)
2	19 (3.4)	20 (10.6)
3	4 (0.7)	1 (0.5)
PMI, mm²/height m² (median, IQR)	486.1 (380.8–599.1)	259.2 (218.9–346.2)	< 0.001
Treatment (N, %)			< 0.001
Antibiotics only	104 (18.7)	39 (20.6)
Cholecystectomy	93 (16.7)	7 (3.7)
ERCP combined	52 (9.4)	21 (11.1)
ERCP only	234 (42.1)	78 (41.3)
Percutaneous drainage	73 (13.1)	44 (23.3)
ICU admission (N, %)	62 (11.2)	50 (26.5)	< 0.001
LOS, day (median, IQR)	8 (6–11)	10 (7–14)	< 0.001
Mortality on 14-day (N, %)	3 (0.6)	6 (3.4)	0.015
In-hospital Mortality (N, %)	4 (0.7)	11 (5.8)	< 0.001
Inotropic agents in ER (N, %)	26 (4.7)	22 (11.6)	0.001
Intubation in ER (N, %)	2 (0.4)	8 (4.2)	< 0.001

BMI, body mass index; COPD, chronic obstructive pulmonary disease; CKD, chronic kidney disease; CVA, cerebral vascular accident; SBP, systolic blood pressure; DBP, mean blood pressure; MAP, mean arterial pressure; HR, heart rate; RR, respiratory rate; BT, body temperature; WBC, white blood cell; BUN, blood urea nitrogen; CRP, C-reactive protein; SOFA, sequential organ failure assessment; PMI, psoas muscle index; ICU, intensive care unit; LOS, length of hospital stay.

Table 2

Multivariate logistic analysis with ICU admission and in-hospital mortality
ICU admission	Multivariate analysis	In-hospital mortality	Multivariate analysis
Variables	OR (95% CI)	Variables	OR (95% CI)
Albumin	0.397 (0.259–0.610)	MAP	0.953 (0.918–0.989)
BUN	1.018 (1.003–1.033)	Albumin	0.339 (0.115–0.997)
MAP	0.965 (0.952–0.979)	BUN	1.031 (1.005–1.058)
O₂ saturation	0.911 (0.860–0.965)	Sarcopenia	3.807 (1.076–13.467)
Sarcopenia	1.569 (1.003–2.546)	O2 saturation	0.984 (0.855–1.133)
CRP	1.009 (0.952–1.038)	Age	1.028 (0.965–1.095)
Age	1.005 (0.987–1.024)

ICU, intensive care unit; BUN, blood urea nitrogen; CRP, C-reactive protein; MAP, mean arterial pressure.

Table 3

Subgroup analysis comparing the prognosis of biliary sepsis treatment strategies between sarcopenic and non-sarcopenic groups
	Non-Sarcopenic	Sarcopenic	P
Antibiotics only	104	39
ICU admission (N, %)	14 (13.5)	12 (30.8)	0.032
In-hospital Mortality (N, %)	1 (1.0)	5 (12.8)	0.007
Percutaneous drainage	73	44
ICU admission (N, %)	72 (98.6)	41 (93.2)	0.050
In-hospital Mortality (N, %)	1 (1.4)	3 (6.8)	0.296
ERCP only	234	78
ICU admission (N, %)	19 (8.1)	13 (16.7)	0.052
In-hospital Mortality (N, %)	2 (0.9)	3 (3.8)	0.193
ERCP combined	52	21
ICU admission (N, %)	4 (7.7)	4 (19.0)	0.321
In-hospital Mortality (N, %)	0 (0.0)	0 (0.0)
Surgery	93	7
ICU admission (N, %)	6 (6.5)	1 (14.3)	0.988
In-hospital Mortality (N, %)	0 (0.0)	0 (0.0)	1.000

No competing interests reported.

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published 22 Jan, 2024

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Can sarcopenia predict poor prognosis of sepsis due to biliary sepsis?

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