Subphenotypes and the De Ritis ratio for mortality risk stratification in sepsis-associated acute liver injury: a retrospective cohort study.

Summary

Across two ICU databases, sepsis patients with liver injury had markedly higher 30-day mortality. The De Ritis (AST/ALT) ratio most strongly stratified mortality risk: ≤1 showed no significant increase, 1–2 increased risk (HR 1.56), and ≥2 had the highest risk (HR 2.46), with external validation.

Key Findings

• Sepsis-associated liver injury doubled 30-day mortality risk versus no SALI (HR 1.73).
• De Ritis ratio stratified mortality: ≤1 (no significant increase), 1–2 (HR 1.56), ≥2 (HR 2.46).
• Findings replicated in an external ICU cohort; R-factor and ALT elevation also stratified but were weaker.

Clinical Implications

Incorporate the De Ritis ratio into early assessment of sepsis with suspected liver injury to identify high-risk patients (AST/ALT ≥1), prioritize monitoring, and consider targeted interventions.

Limitations

• Retrospective design with potential residual confounding.
• AST/ALT can be influenced by extrahepatic sources (e.g., muscle injury), potentially affecting specificity.

Future Directions

Prospective validation and integration of De Ritis ratio into sepsis risk scores; evaluate whether ratio-guided protocols improve outcomes.