While respiratory failure is the hallmark of acute respiratory distress syndrome (ARDS), critically ill patients often experience multi-organ dysfunction, including liver injury. Among these, hypoxic liver injury—also referred to as hypoxic hepatitis or ischemic hepatitis—has been relatively understudied in ARDS populations until now. This single-center observational study analyzed 434 adult patients with moderate to severe ARDS who required invasive mechanical ventilation for more than 48 hours.
Key Findings
The study found that 22.4% of ARDS patients developed HLI during their ICU stay—more than double the incidence typically reported in general ICU populations. Importantly, the occurrence of HLI was strongly associated with worse clinical outcomes. Patients who developed HLI had significantly higher ICU mortality rates compared to those who did not (74.2% vs. 58.2%). Even after adjusting for confounding factors, HLI remained independently associated with a 71% increased risk of death. These findings underscore the severity of HLI as a complication and its potential role as an indicator of systemic deterioration. The study also identified key factors associated with the development of HLI. Notably, patients requiring renal replacement therapy (RRT) were nearly five times more likely to develop HLI. Additionally, the presence of cholestasis—another form of liver dysfunction—was significantly associated with increased risk. These findings suggest that HLI may not occur in isolation but rather as part of a broader syndrome of multi-organ failure driven by systemic hypoxia and impaired perfusion. The study led by Dr. Kevin Roedl from the University Medical Center Hamburg-Eppendorf, Germany, was made available online on May 09, 2026 in the Journal of Intensive Medicine .
Insights into Disease Mechanisms
Despite severe respiratory impairment in all patients, oxygenation levels (PaO₂/FiO₂ ratios) were comparable between those with and without HLI. This suggests that the development of liver injury is not solely dependent on the severity of lung dysfunction but may reflect a more complex interplay of systemic hypoxia, circulatory compromise, and metabolic stress.
Clinical Implications
The findings of this study carry important implications for critical care practice. Early recognition of HLI in ARDS patients could help clinicians identify individuals at particularly high risk of deterioration and mortality. Monitoring liver function markers may therefore provide valuable prognostic information and support clinical decision-making.
Study Strengths and Limitations
A major strength of the study lies in its well-defined and homogeneous patient cohort, consisting exclusively of mechanically ventilated patients with moderate to severe ARDS. This enhances the reliability of the findings within this specific population. However, as a retrospective single-center study, the results are subject to inherent limitations, including potential unmeasured confounding factors.
Conclusion
This study demonstrates that hypoxic liver injury is a common complication affecting more than one in five patients with severe ARDS and is strongly associated with increased mortality. As such, HLI may serve as a valuable prognostic marker and a reflection of systemic disease severity in critically ill patients.
Reference
Title of original paper: Occurrence of hypoxic liver injury in patients with acute respiratory distress syndrome: A retrospective cohort study
Journal: Journal of Intensive Medicine
DOI: https://doi.org/10.1016/j.jointm.2026.02.006
About Dr. Kevin Roedl from the University Medical Center Hamburg-Eppendorf, Germany
Dr. Kevin Roedl is a specialist in Internal Medicine, Intensive Care Medicine, and Pulmonology, serving as a Senior Consultant in the Department of Intensive Care Medicine at the University Medical Center Hamburg-Eppendorf in Hamburg, Germany. His clinical and academic work focuses on the management of critically ill patients, with particular expertise in advanced intensive care and respiratory medicine. His research interests include cardiac arrest and post-resuscitation care, liver disease in critically ill patients, and the optimization of care for elderly patients in the intensive care setting. Dr. Roedl has contributed to numerous clinical studies and is actively involved in advancing evidence-based critical care medicine and improving patient outcomes.
Funding information
This study was supported exclusively by institutional funds of the Department of Intensive Care Medicine.
Journal of Intensive Medicine
Observational study
People
: Occurrence of hypoxic liver injury in patients with acute respiratory distress syndrome: A retrospective cohort study
9-May-2026
Fabian Gleibs, Josephine Braunsteiner, Markus Haar, Marlene Fischer, and Kevin Roedl do not report any conflicts of interest. Stefan Kluge received research support by Ambu, E.T.View Ltd, Fisher & Paykel, Pfizer and Xenios, lecture honoraria from ArjoHuntleigh, Astellas, Astra, Basilea, Bard, Baxter, Biotest, CSL Behring, CytoSorbents, Fresenius, Gilead, MSD, Orion, Pfizer, Philips, Sedana, Sorin, Xenios and Zoll, and consultant honorarium from AMOMED, Astellas, Baxter, Bayer, Fresenius, Gilead, MSD, Pfizer and Xenios.