Prognosis of cirrhotic patients admitted to intensive care unit: a meta-analysis

Abstract

BackgroundThe best predictors of short- and medium-term mortality of cirrhotic patients receiving intensive care support are unknown.MethodsWe conducted meta-analyses from 13 studies (2523 cirrhotics) after selection of original articles and response to a standardized questionnaire by the corresponding authors. End-points were in-ICU, in-hospital, and 6-month mortality in ICU survivors. A total of 301 pooled analyses, including 95 analyses restricted to 6-month mortality among ICU survivors, were conducted considering 249 variables (including reason for admission, organ replacement therapy, and composite prognostic scores).ResultsIn-ICU, in-hospital, and 6-month mortality was 42.7, 54.1, and 75.1%, respectively. Forty-eight patients (3.8%) underwent liver transplantation during follow-up. In-ICU mortality was lower in patients admitted for variceal bleeding (OR 0.46; 95% CI 0.36–0.59; p < 0.001) and higher in patients with SOFA > 19 at baseline (OR 8.54; 95% CI 2.09–34.91; p < 0.001; PPV = 0.93). High SOFA no longer predicted mortality at 6 months in ICU survivors. Twelve variables related to infection were predictors of in-ICU mortality, including SIRS (OR 2.44; 95% CI 1.64–3.65; p < 0.001; PPV = 0.57), pneumonia (OR 2.18; 95% CI 1.47–3.22; p < 0.001; PPV = 0.69), sepsis-associated refractory oliguria (OR 10.61; 95% CI 4.07–27.63; p < 0.001; PPV = 0.76), and fungal infection (OR 4.38; 95% CI 1.11–17.24; p < 0.001; PPV = 0.85). Among therapeutics, only dopamine (OR 5.57; 95% CI 3.02–10.27; p < 0.001; PPV = 0.68), dobutamine (OR 8.92; 95% CI 3.32–23.96; p < 0.001; PPV = 0.86), epinephrine (OR 5.03; 95% CI 2.68–9.42; p < 0.001; PPV = 0.77), and MARS (OR 2.07; 95% CI 1.22–3.53; p = 0.007; PPV = 0.58) were associated with in-ICU mortality without heterogeneity. In ICU survivors, eight markers of liver and renal failure predicted 6-month mortality, including Child–Pugh stage C (OR 2.43; 95% CI 1.44–4.10; p < 0.001; PPV = 0.57), baseline MELD > 26 (OR 3.97; 95% CI 1.92–8.22; p < 0.0001; PPV = 0.75), and hepatorenal syndrome (OR 4.67; 95% CI 1.24–17.64; p = 0.022; PPV = 0.88).ConclusionsPrognosis of cirrhotic patients admitted to ICU is poor since only a minority undergo liver transplant. The prognostic performance of general ICU scores decreases over time, unlike the Child–Pugh and MELD scores, even recorded in the context of organ failure. Infection-related parameters had a short-term impact, whereas liver and renal failure had a sustained impact on mortality.Electronic supplementary materialThe online version of this article (doi:10.1186/s13613-017-0249-6) contains supplementary material, which is available to authorized users.

Survival and predictors of outcome among patients with decompensated liver disease in a non‐liver transplant intensive care unit. Pessimism is historical and unjustified

“…The observed hospital mortality of 37% in this series is comparable to recent findings from overseas and the ANZICS APD registry analysis of cirrhotic patients, justifying the proposition for improved access to intensive care for these patients . The majority of data currently are from single‐centre and larger registry trials in both the United States and the United Kingdom which include specialist liver and liver transplant centres which may bias results . While we recognise the external validity of large registry studies, their primary intention of data collection is for quality surveillance and hence standardised data entry across all centres cannot be ascertained for accuracy including any absent specific data for a clinical question proposed following data collection.…”

“…This may be due to the underestimated true population as more than half of the cohort had mixed aetiologies of liver disease but were only analysed based on their primary aetiology of liver disease. A 2017 meta‐analysis on 13 eligible studies over a 10‐year period, on the prognosis of 2523 cirrhotic patients admitted to ICU did not find a difference in outcome with alcohol‐induced cirrhosis. In contrast, Kings College data suggested an increased ROD, with OR 1.51 (95% CI: 1.42–1.62, P < 0.001), in alcohol‐related liver disease in over 31 000 patients.…”

“…A series in the United Kingdom comprising of 635 cirrhotic patients from 1989 to 2012 admitted to a tertiary referral intensive care unit (ICU) for liver disease and transplantation demonstrated a 30‐day or in‐hospital mortality of 48–87%, with greater mortality associated with increasing organ dysfunction . More recently, literature from the United States and the United Kingdom has challenged the previously accepted bleak outcomes for patients with cirrhosis and organ failure reporting mortality rates of 39–54% . The Kings College group conducted a national retrospective clinical audit in ICU within England, Wales and Northern Ireland .…”

“…[5][6][7] More recently, literature from the United States and the United Kingdom has challenged the previously accepted bleak outcomes for patients with cirrhosis and organ failure reporting mortality rates of 39-54%. [7][8][9][10][11] The Kings College group conducted a national retrospective clinical audit in ICU within England, Wales and Northern Ireland. 12 In the analysis of 31 363 patients between 1998 and 2012, there was a reported 10% reduction (41-31%) in ICU mortality and 12% reduction (58-46%) in-hospital mortality over a 14-year period in those with decompensated cirrhosis presenting to ICU, despite no significant change in the acuity of patients admitted.…”

Acute-on-chronic liver failure: Objective admission and support criteria in the intensive care unit

“…Despite the potential for clinical improvement, mortality is high in this patient population, especially in those with multiorgan failure and septic shock. 73 Continued utilisation of intensive care therapies may become futile as the prognosis for patients with ACLF admitted to the ICU remains fairly poor. Overall, it appears that the early clinical course in patients with ACLF helps to determine the prognosis.…”