Research ArticleProspective evaluation of the prognostic scores for cirrhotic patients admitted to an Intensive Care Unit
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.
References (43)
- et al.
Predictors of mortality and resource utilization in cirrhotic patients admitted to the medical ICU
Chest
(2001) - et al.
Short-term prognosis in critically ill patients with cirrhosis assessed by prognostic scoring systems
Hepatology
(2001) - et al.
Predictors of long-term mortality in patients with cirrhosis of the liver admitted to a medical ICU
Chest
(2004) - et al.
Evidence-based incorporation of serum sodium concentration into MELD
Gastroenterology
(2006) - et al.
United Network for Organ Sharing Liver Disease Severity Score Committee. Model for end-stage liver disease (MELD) and allocation of donor livers
Gastroenterology
(2003) - et al.
The standardization of bronchoscopic techniques for ventilator-associated pneumonia
Chest
(1992) - et al.
Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites
Gastroenterology
(1993) - et al.
The systemic inflammatory response syndrome in cirrhotic patients: relationship with their in-hospital outcome
J Hepatol
(2009) - et al.
Prognosis of patients with cirrhosis and chronic liver disease admitted to the medical intensive care unit
Crit Care Med
(1988) - et al.
Outcome of patients with cirrhosis requiring intensive care unit support: prospective assessment of predictors of mortality
J Gastroenterol
(1998)