Prognosis of cirrhotic patients admitted to intensive care unit: a meta-analysis (original) (raw)
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Prognosis of cirrhotic patients admitted to the general ICU
Annals of Intensive Care, 2016
Background: The prognosis of cirrhotic patients admitted to the ICU is considered to be poor but has been mainly reported in liver ICU. We aimed to describe the prognosis of cirrhotic patients admitted to a general ICU, to assess the predictors of mortality in this population, and, finally, to identify a subgroup of patients in whom intensive care escalation might be discussed. Results: We performed a retrospective monocentric study of all cirrhotic patients consecutively admitted between 2002 and 2014 in a general ICU in a regional university hospital. Two hundred and eighteen cirrhotic patients were admitted to the ICU. The 28-day and 6-month mortality rates were 53 and 74 %, respectively. Among the 115 patients who were discharged from ICU, only eight patients underwent liver transplantation, whereas 48 had no clear contraindication. Multivariable analyses on 28-day mortality identified three independent variables, incorporated into a new three-variable prognostic model as follows: SOFA ≥ 12 (OR 4.2 [2.2-8.0]; 2 points), INR ≥ 2.6 (OR 2.5 [1.3-4.8]; 1 point), and renal replacement therapy (OR 2.3 [1.1-5.1]; 1 point). For a value of the score at 4 (16 % of patients), 28-day and 3-month mortality rates were 91 and 100 %, respectively. An external validation of the score among 149 critically ill cirrhotic patients showed a good accuracy for predicting in-ICU mortality. Conclusions: Mortality of cirrhotic patients admitted to a general ICU was comparable to that of other studies. A pragmatic score integrating the SOFA score, INR, and the need for extrarenal epuration was strongly associated with mortality. Among the 16 % of patients presenting with score 4 at ICU admission, 100 % died in the 3-month follow-up period. The prognostic evaluation on day 3 remains essential for the majority of patients. However, this score calculable at ICU admission might identify patients in whom the benefit of intensive care escalation should be discussed, in particular when liver transplantation is contraindicated.
2013
Mortality is increased in cirrhotic patients admitted in ICU whatever the admission reason. Prognosis scores assessed in critically ill cirrhotic patients in ICU can be classified in three main categories: liver-specific (CTP and MELD) scores, general (SAPS II and APACHE) scores, and organ failure (OSF and SOFA) scores. The components of the liver-specific scores can be influenced by the acute disease indicating the admission to ICU but those of the non liverspecific scores can be influenced by the underlying liver cirrhosis. Many studies reported that organ failure scores are the best predictors of outcome in cirrhotic patients in ICU. We may wonder if cirrhotic patients with acute organ failures should receive prioritization for organ allocation to save their life or should be denied for a potential futile LT. According to recent studies, the SOFA score is associated with a higher risk of death for patients waiting for LT but could not be associated with a worse outcome after LT. It becomes of paramount importance to correctly identify the cirrhotic patients who will maximally benefit from LT after admission to ICU. The EASL-CLIF Consortium defines the CLIF-SOFA score, redefining the SOFA score with cutoff levels based on mortality prediction. The CLIF-SOFA could represent the ideal score in ICU since it is based on organ failures with cutoff values specifically identified in cirrhotic patients. The validation of the CLIF-SOFA score in critically ill cirrhotic patients admitted to ICU and its usefulness to identify patients who could benefit from LT should be the next steps.
Outcome predictors of cirrhosis patients admitted to the intensive care unit
European Journal of Gastroenterology & Hepatology, 2004
Objective To evaluate outcome predictors of patients with cirrhosis admitted to an intensive care unit (ICU). Methods One hundred and twenty-nine consecutive patients with cirrhosis admitted to the ICU at a tertiary care transplant centre in Saudi Arabia between March 1999 and December 2000 were entered prospectively in an ICU database. Liver transplantation patients and readmissions to the ICU were excluded. The following data were documented: demographic features, severity of illness measures, parameters of organ failure, presence of gastrointestinal bleeding, and sepsis. The need for mechanical ventilation, renal replacement therapy and pulmonary artery catheter placement was recorded. The primary endpoint was hospital outcome. Results Cirrhotic patients admitted to the ICU had high hospital mortality (73.6%). However, the actual mortality was not significantly different from the predicted mortality using prediction systems. There was an association between the number of organs failing and mortality. Coma and acute renal failure emerged as independent predictors of mortality. All patients who were monitored with pulmonary artery catheterisation in this study died. Patients requiring mechanical ventilation and renal replacement therapy had very high mortalities (84% and 89%, respectively). All 13 cirrhotic patients admitted to ICU immediately post-cardiac arrest in this study died. Conclusions Cirrhotic patients admitted to ICU have a poor prognosis, especially when admitted with coma, acute renal failure or post-cardiac arrest. The consistently poor prognosis associated with certain ICU interventions should raise new awareness regarding limitations of medical therapy. These mortality statistics compel a critical re-examination of uniformly aggressive life support for the critically ill cirrhotic patient, a percentage of whom will not benefit from invasive measures.
Prognosis of cirrhotic patients admitted to Emergency Departments: A multicenter study
The American Journal of Emergency Medicine, 2019
Objectives: Life threatening complications can occur at any stage of cirrhosis progression. There are few studies on the prognosis of cirrhotic patients managed in an Emergency Department (ED) although management of patients will occur in the ED. The objective of our study was to determine the risk factors for mortality in cirrhotic patients who visited to the ED. METHODS: All cirrhotic patients attending ED in three different university hospitals of Assistance Publique-Hôpitaux de Paris between January 2014 and June 2015 were identified by a retrospective analysis of digital records and included in the study. The primary end-point was 30-day mortality in all cirrhotic patients who visited the ED. RESULTS: A total of 609 ED visits were analyzed among 224 patients: 115 (51%) presented a cirrhosis of alcoholic origin, 43 (19%) were caused by Hepatitis C, 28 (13%) of mixed origin (viral and alcoholic), 17 (8%) were caused by Hepatitis B and 21 (9%) of other origins. Fifty-five (25%) of these patients died within 30 days of their initial presentation to the ED. In multivariate analysis, the age (Odds
Multiple Organ System Failure in Critically Ill Cirrhotic Patients
Digestion, 2004
The prognosis for critically ill cirrhotic patients depends on the extent of hepatic and extrahepatic organ dysfunction/failure. We hypothesize that a graded multiple organ dysfunction score, sequential organ failure assessment (SOFA), would provide more descriptive and discriminative power for predicting the hospital mortality for critically ill cirrhotic patients than the classical organ system failure (OSF) score, which defines organ failure as an all-or-none phenomenon. Methods: 160 patients diagnosed with liver cirrhosis were admitted to the medical intensive care unit (ICU) from January 2002 to June 2003. Information considered necessary for calculating the Child-Pugh, OSF and SOFA scores on ICU admission was collected prospectively. Results: Hepatitis B infection was the most common cause of liver cirrhosis. A significantly progressive increase in mortality rate was associated with OSF and SOFA scores (p ! 0.001). Close correlation between OSF and SOFA scores (p ! 0.001) suggested that both systems evaluated the same event. In patients with similar organ dysfunction, the number of failed organ system(s) was significantly higher among non-survivors. However, no correlation existed between the SOFA scores and mortality rate in patients with the same OSF number. Meanwhile, both OSF and SOFA scores displayed excellent discriminative power (areas under receiver-operating characteristic (AUROC) were 0.906 and 0.892, respectively), while Child-Pugh scores clearly performed more poorly (AU-ROC 0.712). Both OSF and SOFA demonstrate a good fit using the Hosmer and Lemeshow goodness-of-fit test. Conclusions: Both OSF and SOFA scores are excellent tools for predicting prognosis for cirrhotic patients admitted to ICU. Both of them are superior to Child-Pugh score. Hospital mortality for critically ill cirrhotic patients occurs owing to severe failure of a relatively few organs, rather than because of an accumulation of mild dysfunction in many organ systems. Graded organ dysfunction scales provide no further benefit for predicting hospital mortality for critically ill cirrhotic patients.
Prognostic markers in cirrhotic patients requiring intensive care: a comparative prospective study
Annals of hepatology
The use of prognostic models for cirrhotic patients admitted to the medical intensive care unit (ICU) is of great importance, since they provide an objective evaluation for a group of patients with high mortality rates and high resource utilization. To evaluate the validity and to compare the prognostic predictive value of the CTP, MELD, SOFA and APACHE II scoring systems in cirrhotic patients admitted to the ICU, the CTP and MELD models being exclusive for patients with liver disease. Commonly used predictors of mortality such as age, sex, CTP, MELD, APACHE II and SOFA were evaluated, and their prognostic value was investigated. A total of 201 patients were included in this study. Patients who survived had mean CTP score of 9.5 ± 2.4, MELD score 18.1 ± 7.1, APACHE II score of 13.4 ± 4.8 and SOFA score of 4.2 ± 2.6, compared to respective scores of 11.4 ± 2.8, 28.0 ± 11.2, 24.6 ± 10.4 and 8.7 ± 4.0 in patients who died. The difference between groups was statistically significant for...