Survival Determinants in Hypoxic Hepatitis Among Critically Ill Patients: A Systematic Review and Meta-Analysis

BackgroundHypoxic hepatitis (HH), also termed ischemic hepatitis or shock liver, is an acute hepatocellular injury caused by an imbalance between hepatic oxygen supply and demand. It develops secondary to cardiac, circulatory, or respiratory failure through reduced hepatic blood flow, systemic hypoxemia, hepatic venous congestion, or impaired cellular oxygen utilization. Although its recognition in critical care has increased, the clinical and biochemical factors distinguishing survivors from non-survivors remain poorly defined. This analysis aimed to characterize these differences among critically ill adults diagnosed with HH.MethodsThis systematic review and meta-analysis followed PRISMA guidelines and was pre-registered in PROSPERO (CRD420251180238). A comprehensive search of PubMed, Scopus, Web of Science, EMBASE, Cochrane, LILACS, CNKI, CINAHL, and Google Scholar was conducted on July 4, 2025. Eligible studies included critically ill patients diagnosed with HH. Random-effects meta-analyses were performed in R.ResultsOf 3236 identified records, five cohort studies comprising 107,346 participants were included. The pooled mean difference in age between survivors and non-survivors was -5.1 years (p = 0.03; I² = 23.1%). Mechanical ventilation was associated with lower survival (RR = 0.76; p < 0.01; I² = 0.7%), and norepinephrine or other hemodynamic support was associated with lower odds of survival (OR = 0.4; p < 0.01; I² = 5.5%). In contrast, lactate, bilirubin, and INR were not significantly associated with survival.ConclusionHypoxic hepatitis should be interpreted primarily as a secondary marker of severe cardiac, circulatory, or respiratory failure rather than as an isolated primary driver of mortality. Its occurrence may be associated with increased mortality in critically ill patients; however, the available evidence is limited by the small number of eligible studies and heterogeneity. Further standardized, prospective studies are needed to clarify its independent prognostic significance.