The Royal Free Hospital Score: A Calibrated Prognostic Model for Patients With Cirrhosis Admitted to Intensive Care Unit. Comparison With Current Models and CLIF-SOFA Score

Abstract

OBJECTIVES:Prognosis for patients with cirrhosis admitted to intensive care unit (ICU) is poor. ICU prognostic models are more accurate than liver-specific models. We identified predictors of mortality, developed a novel prognostic score (Royal Free Hospital (RFH) score), and tested it against established prognostic models and the yet unvalidated Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) model.METHODS:Predictors of mortality were defined by logistic regression in a cohort of 635 consecutive patients with cirrhosis admitted to ICU (1989–2012). The RFH score was derived using a 75% training and 25% validation set. Predictive accuracy and calibration were evaluated using area under the receiver operating characteristic (AUROC) and goodness-of-fit χ2 for the RFH score, as well as for SOFA, Model for End-Stage Liver Disease (MELD), Acute Physiology and Chronic Health Evaluation (APACHE II), and Child-Pugh. CLIF-SOFA was applied to a recent subset (2005–2012) of patients.RESULTS:In-hospital mortality was 52.3%. Mortality improved over time but with a corresponding reduction in acuity of illness on admission. Predictors of mortality in training set, which constituted the RFH score, were the following: bilirubin, international normalized ratio, lactate, alveolar arterial partial pressure oxygen gradient, urea, while variceal bleeding as indication for admission conferred lesser risk. Classification accuracy was 73.4% in training and 76.7% in validation sample and did not change significantly across different eras of admission. The AUROC for the derived model was 0.83 and the goodness-of-fit χ2 was 3.74 (P=0.88). AUROC for SOFA was 0.81, MELD was 0.79, APACHE II was 0.78, and Child-Pugh was 0.67. In 2005–2012 cohort, AUROC was: SOFA: 0.74, CLIF-SOFA: 0.75, and RFH: 0.78. Goodness-of-fit χ2 was: SOFA: 6.21 (P=0.63), CLIF-SOFA: 9.18 (P=0.33), and RFH: 2.91 (P=0.94).CONCLUSIONS:RFH score demonstrated good discriminative ability and calibration. Internal validation supports its generalizability. CLIF-SOFA did not perform better than RFH and the original SOFA. External validation of our model should be undertaken to confirm its clinical utility.

Early invasive fungal infections and colonization in patients with cirrhosis admitted to the intensive care unit

“…These observations are in keeping with the fact that cirrhosis is an independent risk factor for worse outcomes and increased mortality in ICU. Despite the advances in medical care, in-hospital mortality in patients with cirrhosis admitted to ICU with acute decompensation remains high (approximately 30% in more recent cohorts), and is significantly higher in those with more advanced liver disease (Child-Pugh class A 0%, class B 26%, class C 61%) [17]. In our cohort the in-hospital mortality was only 12.1%, which most likely reflects the over-representation of patients with compensated cirrhosis (Child-Pugh class A) and the admission to ICU for indications other than acute decompensation.…”

A modified prognostic score for critically ill patients with cirrhosis: An observational study

“…3,21,22 This cohort study was designed to establish a disease-specific prognostic score that may help the physicians to make better clinical judgment decisions to prioritize the allocation of resources of ICU.…”

“…The clinical outcome of ICU-managed patients with cirrhosis appears to improve with the progressively improving armamentarium of sophisticated technology. 3,4 However, the mortality of patients with cirrhosis in the ICU remains high, varying from 34.7% to 90%. [5][6][7][8] The therapeutic effectiveness of life support is currently disputed.…”

“…19,20 However, these scores are constructed on the basis of various severe illnesses other than cirrhosis alone, and the use of these scores is limited by their complexity. To the best of our knowledge, only a few prognostic scores have been specifically developed from cohorts of critically ill patients with cirrhosis, 3,21,22 and there are no models derived from Chinese populations.…”

Falla hepática aguda sobre crónica

“…Las enfermedades hepáticas agudas o crónicas pueden llevar a diferentes manifestaciones neurológicas que en conjunto se denominan encefalopatía hepática, las cuales están mediadas por dos eventos: el shunting portosistémico y la insuficiencia hepática (EH) (27). El proceso fisiopatoló-gico común se basa en el paso a la circulación sistémica de sustancias nitrogenadas no depuradas por el hígado (como el amonio) y que proceden del intestino, alterando la función del sistema nervioso (28).…”