Elsevier

Journal of Hepatology

Volume 56, Issue 1, January 2012, Pages 95-102
Journal of Hepatology

Research Article
Prospective evaluation of the prognostic scores for cirrhotic patients admitted to an Intensive Care Unit

https://doi.org/10.1016/j.jhep.2011.06.024Get rights and content

Background & Aims

Cirrhotic patients admitted to an Intensive Care Unit (ICU) have a poor prognosis. Identifying patients in whom ICU care will be useful can be challenging. The aim of this study was to assess the predictive value of prognostic scores with respect to mortality and to identify mortality risk factors.

Methods

Three hundred and seventy-seven cirrhotic patients admitted to a Liver ICU between May 2005 and March 2009 were enrolled in this study. Their average age was 55.5 ± 11.4 years. The etiology of cirrhosis was alcohol (68%), virus hepatitis (18%), or mixed (5.5%). The main causes of hospitalization were gastrointestinal hemorrhage (43%), sepsis (19%), and hepatic encephalopathy (12%).

Results

ICU and in-hospital mortality rates were 34.7% and 43.0%, respectively. Infection was the major cause of death (81.6%). ROC curve analysis demonstrated that SOFA (0.92) and SAPS II (0.89) scores calculated within 24 h of admission predicted ICU mortality better than the Child–Pugh score (0.79) or MELD scores with (0.79–0.82) or without the incorporation of serum sodium levels (0.82). Statistical analysis showed that the prognostic severity scores, organ replacement therapy, and infection were accurate predictors of mortality. On multivariate analysis, mechanical ventilation, vasopressor therapy, bilirubin level at admission, and infection were independently associated with ICU mortality.

Conclusions

For cirrhotic patients admitted to the ICU, SAPS II, and SOFA scores predicted ICU mortality better than liver-specific scores. Mechanical ventilation or vasopressor therapy, bilirubin levels at admission and infection in patients with advanced cirrhosis were associated with a poor outcome.

Introduction

Cirrhotic patients admitted to an Intensive Care Unit (ICU) have a poor prognosis, with mortality rates ranging from 36% to 86% [1], [2], [3], [4]. In addition, management of these patients requires that a significant percentage of the total ICU care budget is devoted to a subgroup of cirrhotic patients who will eventually not survive [5], [6].

To identify patients in whom aggressive treatment may offer recovery, or those who may benefit from a transfer to an ICU or from liver transplantation, has always been a challenge for intensivists and hepatologists. To this end, several prognostic scores [7], [8] have been proposed, including the Child–Pugh, which until now has been the most widely utilized liver-specific score [9], [10]. However, the discriminatory power of this score relative to mortality in cirrhotic patients admitted to the ICU is inferior to that of general ICU scores (SOFA or APACHE) [11]. This might be due, at least in part, to the fact that the Child–Pugh score does not include any markers of renal function.

Recently, the Model for End-Stage Liver Disease (MELD) score, initially developed for cirrhotic patients treated with Transjugular Intrahepatic Portosystemic Shunt (TIPS) [12], has been applied widely to predict mortality across a broad spectrum of liver diseases. Thus, the MELD score was implemented in 2002 by the United Network for Organ Sharing (UNOS) as a tool to estimate the severity of liver disease, the mortality of patients on waiting lists for liver transplantation and subsequently for the allocation of liver grafts. The MELD score has been associated with 3-month mortality in patients on the waiting list. Despite its potential benefits, relatively few studies have analyzed the predictive value of the MELD score in cirrhotic patients admitted to an Intensive Care Unit [13], [14], [15]. Moreover, hyponatremia, as a surrogate of portal hypertension, has now been recognized as an important prognostic factor in patients with liver cirrhosis [16]. Several MELD models incorporating serum sodium (Na+) levels (the MELD-Na [16], iMELD [17], and MESO [18]) have been shown to improve prognostic accuracy in cirrhotic patients awaiting liver transplantation [19], [20]. However, only one study has evaluated these modified versions (MELD combined with serum sodium) in cirrhotic patients admitted to an ICU and observed a similar discrimination ability of MELD-Na and MELD to predict in-hospital mortality [15].

To evaluate the performance of these scores as predictive tools of mortality in patients with cirrhosis in an ICU, we compared the Child–Pugh classification, liver-specific prognostic models (MELD and MELD combined with serum sodium) and two ICU prognostic scores [the Simplified Acute Physiology Score (SAPS II) [21] and Sequential Organ Failure Assessment (SOFA)] [22]. In addition, we looked for specific factors that might predict mortality in patients with cirrhosis admitted to an ICU.

Section snippets

Patients

This prospective cohort study was performed in the Liver Intensive Care Unit (15 beds) at Paul Brousse University Hospital. This is a tertiary referral unit that has been highly specialized in liver diseases since 1970. The unit is run by hepatologists, intensivists, and liver surgeons. Between May 2005 and March 2009, 377 consecutive cirrhotic patients requiring intensive monitoring and/or treatment that could not be provided outside an ICU were enrolled. All patients were ⩾18 years of age and

Patients

Between May 2005 and March 2009, 377 consecutive cirrhotic patients admitted to our ICU were enrolled in this study. The characteristics of these patients are shown in Table 1. The median age was 55.5 ± 11.4 years; 73% were men and the liver disease concerned was most frequently alcohol-related (68%). The most common primary diagnoses at ICU admission were: acute variceal bleeding (43%), severe infection (19%), or hepatic encephalopathy (13%). Among the patients with alcoholic cirrhosis, 39

Discussion

The main result of this study is that the SAPS II and SOFA scores performed better than standard MELD, MELD incorporating sodium levels and the Child–Pugh score to predict ICU mortality in cirrhotic patients admitted to an ICU.

Our findings agree with those of Cholongitas et al. [11]. In their meta-analysis grouping 21 cohorts from studies published during the past 20 years, these authors observed that liver function was not the main determinant of outcome in cirrhotic patients with multi-organ

Conflict of interest

The authors who have taken part in this study do not have any relationship with the manufacturers of the drugs involved either in the past or present and did not receive any funding from the manufacturer to carry out this research.

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