Improvement in the prognosis of cirrhotic patients admitted to an intensive care unit, a retrospective study

Alcohol related hepatitis in intensive care units: clinical and biological spectrum and mortality risk factors: a multicenter retrospective study

BACKGROUND

Alcohol related hepatitis is responsible for high morbidity and mortality, but little is known about the management of patients with hepatitis specifically in intensive care units (ICU).

METHODS

Retrospective study including patients with alcohol related hepatitis hospitalized in 9 French ICUs (2006-2017). Alcohol related hepatitis was defined histologically or by an association of clinical and biological criteria according to current guidelines.

RESULTS

187 patients (median age: 53 [43-60]; male: 69%) were included. A liver biopsy was performed in 51% of cases. Patients were admitted for impaired consciousness (71%), sepsis (64%), shock (44%), respiratory failure (37%). At admission, median SOFA and MELD scores were 10 [7-13] and 31 [26-40] respectively. 63% of patients received invasive mechanical ventilation, 62% vasopressors, and 36% renal replacement therapy. 66% of patients received corticosteroids, and liver transplantation was performed in 16 patients (8.5%). ICU and in-hospital mortality were 37% and 53% respectively. By multivariate analysis, ICU mortality was associated with SOFA score (without total bilirubin) (SHR 1.08 [1.02-1.14] per one-point increase), arterial lactate (SHR 1.08 [1.03-1.13] per 1 mmol/L) and MELD score (SHR 1.09 [1.04-1.14] per 1 point), while employment was associated with increased survival (HR 0.49 [0.28-0.86]). After propensity score weighting, the use of corticosteroids did not affect ICU mortality in the overall population but had a beneficial effect in the subgroup of patients with histological proof. Patient prognosis was also better in responders assessed by Lille score at day 7 (OR 6.67 [2.44-20.15], p < 0.001).

CONCLUSION

Alcohol related hepatitis is a severe condition leading to high mortality in ICU patients. Severity of organ failure at admission are mortality risk factors. Outcome was significantly better in responders to corticosteroids therapy according to Lille score. Early referral to tertiary centers to discuss liver transplantation should more widely be considered.

Intensive care management of acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined by an acute deterioration of the liver function associated with extrahepatic organ failures requiring intensive care support and associated with a high short-term mortality. ACLF has emerged as a major cause of mortality in patients with cirrhosis and chronic liver disease. ACLF has a unique pathophysiology in which systemic inflammation plays a key role; this provides the basis of novel therapies, several of which are now in clinical trials. Intensive care unit (ICU) therapy parallels that applied in the general ICU population in some organ failures but has peculiar differential characteristics in others. Critical care management strategies and the option of liver transplantation (LT) should be balanced with futility considerations in those with a poor prognosis. Nowadays, LT is the only life-saving treatment that can radically improve the long-term prognosis of patients with ACLF. This narrative review will provide insights on the current understanding of ACLF with emphasis on intensive care management.

The Impact of Chronic Medical Conditions on Mortality in Acute Respiratory Distress Syndrome

PURPOSE

To examine the impact of chronic comorbidities on mortality in Acute Respiratory Distress Syndrome (ARDS).

MATERIALS AND METHODS

Retrospective cohort study of adults with ARDS (ICD-10-CM code J80) from the National Inpatient Sample between January, 2016 and December, 2018. For the primary outcome of mortality, we conducted weighted logistic regression adjusting for factors identified on univariate analysis as potentially significant or differing between the two groups at baseline. We used negative binomial regression adjusting for the same comorbidities to identify risk factors for longer length of stay (LOS) among ARDS survivors.

RESULTS

After exclusions, 1046 records were analyzed (3355 ARDS survivors and 1875 non-survivors.) The comorbidities examined included hypertension, diabetes mellitus, obesity, hypothyroidism, alcohol and drug use, chronic kidney disease (CKD), cardiovascular disease, chronic liver disease, chronic pulmonary disease and malignancy. In multivariate analysis, we found that malignancy (OR 2.26, 95% CI 1.84-2.78, p < 0.001), cardiovascular disease (OR 1.54, 95% CI 1.23-1.92, p < 0.001), and CKD (OR 1.75, 95% CI 1.22-2.50, p  =  0.002) increased the risk of death. In interaction analyses, cardiovascular disease combined with either malignancy or CKD conferred higher odds of death compared to either risk factor alone.

CONCLUSIONS

The comorbidity of malignancy confers the most reliable risk of poor outcomes in ARDS with higher odds of hospital death and a simultaneous association with longer hospital LOS among survivors.

Management of acute renal replacement therapy in critically ill cirrhotic patients

Renal replacement therapy (RRT) in cirrhotic patients encompasses a number of issues related to the particular characteristics of this population, especially in the intensive care unit (ICU) setting. The short-term prognosis of cirrhotic patients with acute kidney injury is poor, with a mortality rate higher than 65% in patients with RRT requirement, raising questions about the futility of its initiation. Regarding the management of the RRT itself, there is still no consensus with respect to the modality (continuous versus intermittent) or the anticoagulation required to improve the circuit life, which is shorter than similar at-risk populations, despite the altered haemostasis in traditional coagulation tests frequently found in these patients. Furthermore, volume management is one of the most complex issues in this cohort, where tools used for ambulatory dialysis have not yet been successfully reproducible in the ICU setting. This review attempts to shed light on the management of acute RRT in the critically ill cirrhotic population based on the current evidence and the newly available tools. We will discuss the timing of RRT initiation and cessation, the modality, anticoagulation and fluid management, as well as the outcomes of the RRT in this population, and provide a brief review of the albumin extracorporeal dialysis from the point of view of a nephrologist.

Management of Decompensated Cirrhosis and Associated Syndromes

Patients with cirrhosis account for 3% of intensive care unit admissions with hospital mortality exceeding 50%; however, improvements in survival among patients with acutely decompensated cirrhosis and organ failure have been described when treated in specialized liver transplant centers. Acute-on-chronic liver failure is a distinct clinical syndrome characterized by decompensated cirrhosis associated with one or more organ failures resulting in a significantly higher short-term mortality. In this review, we will discuss the management of common life-threatening complications in the patient with cirrhosis that require intensive care management including neurologic, cardiovascular, gastrointestinal, pulmonary, and renal complications.

Assessing the prognosis of cirrhotic patients in the intensive care unit: What we know and what we need to know better

Critically ill cirrhotic patients have high in-hospital mortality and utilize significant health care resources as a consequence of the need for multiorgan support. Despite this fact, their mortality has decreased in recent decades due to improved care of critically ill patients. Acute-on-chronic liver failure (ACLF), sepsis and elevated hepatic scores are associated with increased mortality in this population, especially among those not eligible for liver transplantation. No score is superior to another in the prognostic assessment of these patients, and both liver-specific and intensive care unit-specific scores have satisfactory predictive accuracy. The sequential assessment of the scores, especially the Sequential Organ Failure Assessment (SOFA) and Chronic Liver Failure Consortium (CLIF)-SOFA scores, may be useful as an auxiliary tool in the decision-making process regarding the benefits of maintaining supportive therapies in this population. A CLIF-ACLF > 70 at admission or at day 3 was associated with a poor prognosis, as well as SOFA score > 19 at baseline or increasing SOFA score > 72. Additional studies addressing the prognostic assessment of these patients are necessary.

Identifying early indicators of secondary peritonitis in critically ill patients with cirrhosis

Ascitic fluid infection (AFI) is a life-threatening complication of cirrhosis. We aimed to identify early indicators of secondary peritonitis (SP), which requires emergency surgery, and to describe the outcomes of SP and spontaneous bacterial/fungal peritonitis (SBFP). Adults with cirrhosis and AFI admitted to 16 university or university-affiliated ICUs in France between 2002 and 2017 were studied retrospectively. Cases were identified by searching the hospital databases for relevant ICD-10 codes and hospital charts for AFI. Logistic multivariate regression was performed to identify factors associated with SP. Secondary outcomes were short- and long-term mortality and survivors' functional outcomes. Of 178 included patients (137 men and 41 women; mean age, 58 ± 11 years), 21 (11.8%) had SP, confirmed by surgery in 16 cases and by abdominal computed tomography in 5 cases. Time to diagnosis exceeded 24 h in 7/21 patients with SP. By multivariate analysis, factors independently associated with SP were ascitic leukocyte count > 10,000/mm³ (OR 3.70; 95%CI 1.38-9.85; P = 0.009) and absence of laboratory signs of decompensated cirrhosis (OR 4.53; 95%CI 1.30-15.68; P = 0.017). The 1-year mortality rates in patients with SBFP and SP were 81.0% and 77.5%, respectively (Log-rank test, P = 0.92). Patients with SP vs. SBFP had no differences in 1-year functional outcomes. This multicenter retrospective study identified two indicators of SP as opposed to SBFP in patients with cirrhosis. Using these indicators may help to provide early surgical treatment.

pCLIF-SOFA is a reliable outcome prognostication score of critically ill children with cirrhosis: an ESPNIC multicentre study

Background and aims

Data on outcome of critically ill children with cirrhosis are scarce. We aimed to evaluate the prognostic accuracy of sequential organs scoring systems in children with cirrhosis admitted to Paediatric Intensive Care Units (PICU).

Methods

We performed a multicentre retrospective analysis of children with cirrhosis admitted into four European PICUs between 2011 and 2016. Investigators were members of the ESPNIC liver failure and support working group. Paediatric End-Stage Liver Disease (PELD) and paediatric chronic liver failure sequential organ failure assessment score (pCLIF-SOFA) diagnostic accuracy for 28- and 60-day liver transplantation, 28-day mortality and 60-day composite outcome (ie. death or liver transplantation) were tested.

Results

One-hundred-and-thirty children were included. The main causes for PICU admission were acute-on-chronic liver failure (ACLF), gastrointestinal bleeding and sepsis. Twenty-nine percent died and 22.3% were transplanted by day-60 after PICU admission. On multivariable analysis, pCLIF-SOFA was the only predictor of mortality at day-28 and of composite outcome. Both pCLIF-SOFA and ACLF were independently associated with emergent liver transplantation. The pCLIF-SOFA score higher than 9 well predicted a 28-day mortality with a sensitivity of 87.8% and a specificity of 77.3%. A pCLIF-SOFA score higher than 7 was independently associated with liver transplantation on day-60. Stage 3 AKI assessed with KDIGO classification was significantly associated with 28-day mortality.

Conclusions

Half of critically ill cirrhotic children admitted to PICU either died or were transplanted within the initial 28-day period. On admission pCLIF-SOFA score accurately identify patients transplanted at day-28 and day-60 to those alive without LT and is associated with 28-day mortality and composite outcome at day-60.

Sustained low-efficiency dialysis with regional citrate anticoagulation for patients with liver impairment in intensive care unit: A single-center experience

Regional citrate anticoagulation (RCA) is a recommended method for extracorporeal circuit anticoagulation during renal replacement therapy (RRT). Increased risk of citrate accumulation by default of hepatic metabolism limits its use in liver failure patients. A Ca_tot /Ca_ion ratio ≥2.5 is established as an indirect control of plasma citrate poisoning. To investigate the safety of RCA in patients with liver impairment during sustained low-efficiency dialysis (SLED), we conducted a retrospective study of 41 patients with acute or chronic hepatocellular failure requiring RRT between January 2014 and June 2015 in the intensive care unit of the Groupe Hospitalier Sud Ile de France. Sixty-seven SLED sessions were performed. At admission, 32 (78%) patients had acute liver dysfunction and nine (22%) patients had cirrhosis with a median MELD score of 27 (IQR: 18.8, 42.0). Despite a majority of poor prognosis patients (SAPS-II (Simplified Acute Physiology Score II) score 71 [IQR: 58; 87]), with acute liver impairment as a part of multi-organ failure, no dosage of Ca_tot /Ca_ion ratio after SLED sessions exceeded the critical threshold of 2.5. Of the 63 complete sessions, neither dyscalcemia nor major dysnatremia, nor extracorporeal circuit thrombosis were noticed. Observed acid-base disturbances (16.4%) were not significantly correlated with the Ca_tot /Ca_ion ratio (P = .2155). In this retrospective study using RCA during intermittent RRT in ICU patients with severe liver dysfunction, we did not observe any citrate accumulation but monitoring of acid-base status and electrolytes remains necessary to ensure technique safety.

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

BACKGROUND

Recent literature emanating from the United Kingdom and United States has reported decreasing mortality rates in patients with decompensated cirrhosis and organ failures presenting to the intensive care unit (ICU).

AIM

To determine if there were comparable outcomes in a single-centre non-transplant unit in Australia.

METHODS

A retrospective observational study was conducted in a tertiary, non-liver transplant unit in Sydney, Australia. Admission data and mortality outcomes were collected from patients with cirrhosis non-electively admitted to ICU between 2013 and 2017. Liver-specific and general intensive care scoring tools were also assessed for their discriminative ability to predict short-term prognostic outcomes.

RESULTS

Sixty-three patients were admitted with decompensated liver disease who fulfilled the inclusion criteria. The overall hospital mortality was 37% (95% CI: 0.26-0.49). There was no difference in survival based on aetiology of liver disease (P = 0.96) but a significant difference was found based on the presenting diagnosis, with greater survival among patients diagnosed with hepatic encephalopathy on ICU admission (P = 0.02). There was 4% mortality in patients with no organ failure and 52% mortality in those with ≥3 organs in failure (P < 0.001). The ICU prognostic Sequential Organ Failure Assessment score was the better discriminative tool in predicting short-term outcomes when compared to liver prognostic scores.

CONCLUSION

The outcomes of this single-centre Australian study align with current overseas literature. These results reinforce and expand on limited local evidence, corroborating the former universal prognostic pessimism towards cirrhotic patients with organ failure as unwarranted.

A population-based cohort study of mortality of intensive care unit patients with liver cirrhosis

BACKGROUND

The impact of liver cirrhosis on the outcomes of admission to intensive care unit (ICU) is not completely understood. Our purpose is to identify risk factors for mortality in ICU patients with liver cirrhosis.

METHODS

Using reimbursement claims from Taiwan's National Health Insurance Research Database from in 2006-2012, 1,250,300 patients were identified as having ICU stays of more than 1 day, and 37,197 of these had liver cirrhosis. With propensity score-matching for socioeconomic status, pre-existing medical conditions, and cirrhosis-related morbidities, 37,197 ICU patients without liver cirrhosis were selected for comparison. Adjusted odds ratios (ORs) and 95% confidence intervals (CIs) of cirrhosis associated with 30-day, ICU, and one-year mortality were calculated.

RESULTS

Compared with control, cirrhotic patients had higher 30-day mortality (aOR 1.60, 95% CI 1.53 to 1.68), particularly those with jaundice (aOR 2.23, 95% CI 2.03 to 2.45), ascites (aOR 2.32, 95% CI 2.19 to 2.46) or hepatic coma (aOR 2.21, 95% CI 2.07 to 2.36). Among ICU patients, liver cirrhosis was also associated with ICU mortality (aOR 144, 95% CI 1.38 to 1.51) and one-year mortality (aOR 1.40, 95% CI 1.35 to 1.46). Associations between cirrhosis of liver and increased 30-day mortality were significant in both sexes and every age group.

CONCLUSIONS

Liver cirrhosis was associated with 30-day mortality in ICU patients. Jaundice, ascites, hepatic coma, more than 4 admissions due to cirrhosis, and more than 30 days of hospital stay due to cirrhosis were exacerbated factors in cirrhotic ICU patients.

Dynamic Prognostication in Critically Ill Cirrhotic Patients With Multiorgan Failure in ICUs in Europe and North America: A Multicenter Analysis

OBJECTIVES

To evaluate the Chronic Liver Failure-Consortium Acute on Chronic Liver Failure score in acute on chronic liver failure patients admitted to ICUs from different global regions and compare discrimination ability with previously published scores.

DESIGN

Retrospective pooled analysis.

SETTING

Academic ICUs in Canada (Edmonton, Vancouver) and Europe (Paris, Barcelona, Chronic liver failure/Acute-on-Chronic Liver Failure in Cirrhosis [CANONIC] study).

PATIENTS

Sample of analysis of 867 cirrhotic patients with acute on chronic liver failure admitted to ICU. Cumulative incidence functions of death were estimated by acute on chronic liver failure grade at admission and at day 3. Survival discrimination abilities of Chronic Liver Failure-Consortium Acute on Chronic Liver Failure, Model for End-Stage Liver Disease, Acute Physiology and Chronic Health Evaluation II, and Child-Turcotte-Pugh scores were compared.

INTERVENTIONS

ICU admission for organ support.

MEASUREMENTS AND MAIN RESULTS

At admission 169 subjects (19%) had acute on chronic liver failure 1, 302 (35%) acute on chronic liver failure 2, and 396 (46%) had acute on chronic liver failure 3 with 90-mortality rates of 33%, 40%, and 74%, respectively (p < 0.001). At admission, Chronic Liver Failure-Consortium Acute on Chronic Liver Failure demonstrated superior discrimination at 90 days compared with Acute Physiology and Chronic Health Evaluation II (n = 532; concordance index 0.67 vs 0.62; p = 0.0027) and Child-Turcotte-Pugh (n = 666; 0.68 vs 0.64; p = 0.0035), but not Model for End-Stage Liver Disease (n = 845; 0.68 vs 0.67; p = 0.3). A Chronic Liver Failure-Consortium Acute on Chronic Liver Failure score greater than 70 at admission or on day 3 was associated with 90-day mortality rates of approximately 90%. Ninety-day mortality in grade 3 acute on chronic liver failure patients at admission who demonstrated improvement by day 3 was 40% (vs 79% in patients who did not).

CONCLUSIONS

The Chronic Liver Failure-Consortium Acute on Chronic Liver Failure demonstrated better discrimination at day 28 and day 90 compared with Acute Physiology and Chronic Health Evaluation II and Child-Turcotte-Pugh. Patients who demonstrated clinical improvement post-ICU admission (e.g., acute on chronic liver failure 3 to 1 or 2) at day 3 had better outcomes than those who did not. In high-risk ICU patients (Chronic Liver Failure-Consortium Acute on Chronic Liver Failure > 70), decisions regarding transition to palliation should be explored between patient families and the ICU providers after a short trial of therapy.

Palliative care in decompensated cirrhosis: A review

Decompensated cirrhosis is an illness that causes tremendous suffering. The incidence of cirrhosis is increasing and rates of liver transplant, the only cure, remain stagnant. Palliative care is focused on improving quality of life for patients with serious illness by addressing advanced care planning, alleviating physical symptoms and providing emotional support to the patient and family. Palliative care is used infrequently in patients with decompensated cirrhosis. The allure of transplant as a potential treatment option for cirrhosis, misperceptions about the role of palliative care and difficulty predicting prognosis in liver disease are potential contributors to the underutilization of palliative care in this patient population. Studies have demonstrated some benefit of palliative care in patients with decompensated cirrhosis but the literature is limited to small observational studies. There is evidence that palliative care consultation in other patient populations lowers hospital costs and ICU utilization and improves symptom control and patient satisfaction. Prospective randomized control trials are needed to investigate the effects of palliative care on traditional- and patient-reported outcomes as well as cost of care in decompensated cirrhosis for transplant eligible and ineligible patient populations.

Cirrhotic patients admitted to the ICU for medical reasons: Analysis of 5506 patients admitted to 286 ICUs in 8years

PURPOSE

To describe characteristics and prognostic factors of cirrhotic patients admitted to a representative sample of Italian intensive care units (ICUs).

MATERIALS AND METHODS

All patients admitted to 286 ICUs for medical reasons between 2002 and 2010 (excluding 2007) were considered. A logistic regression model was developed on cirrhotics to predict hospital mortality. The prediction was applied to different subgroups defined by both the level of unit expertise with cirrhotics and the overall unit performance, and compared to the actual mortality.

RESULTS

5506 cirrhotic patients (32.1% admitted to the ICU for non-cirrhotic-related reasons) were compared to 130,477 controls. Hospital mortality was higher in cirrhotics (57.2% vs. 35.0%, p<0.001). ICU volume of cirrhotic patients did not influence mortality, while the overall performance of the unit did. The standardized mortality ratio for overall lower-performing units was 1.09 (95%CI: 1.05-1.14), for the average-performing units it was 1.01 (95%CI: 0.98-1.04), for the higher-performing units it was 0.92 (95%CI: 0.89-0.96).

CONCLUSIONS

The outcome of critically ill cirrhotic patients is quite poor, but not to limit their admission to the ICU. When cirrhosis accompanies other acute conditions, the general level of intensive care medicine is more important than the specific liver-oriented expertise in treating these patients.

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

BACKGROUND

The best predictors of short- and medium-term mortality of cirrhotic patients receiving intensive care support are unknown.

METHODS

We 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).

RESULTS

In-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).

CONCLUSIONS

Prognosis 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.

Long-term outcome of patients with liver cirrhosis admitted to a general intensive care unit

OBJECTIVES

The prevalence of liver cirrhosis is increasing, and many patients have acute conditions requiring consideration of intensive care. This study aims to: (a) report the outcome at 12 months of patients with cirrhosis admitted to ICU, (b) identify factors predictive of long-term mortality and (c) evaluate the ability of scoring systems to predict long-term outcome.

DESIGN

Observational cohort study.

SETTING

General adult critical care unit in a UK teaching hospital.

PATIENTS

Eighty-four patients admitted to critical care between June 2012 and December 2013.

PRIMARY OUTCOME MEASURES

Cumulative survival at ICU discharge, hospital discharge and 12 months.

RESULTS

Eighty-four patients with diagnosed cirrhosis were followed up at 12 months. Clinical variables collected at ICU admission were entered into a multivariate regression analysis for mortality and eight predetermined scoring systems calculated. Cumulative survival at ICU discharge, hospital discharge and 12 months was 64.8, 47.1 and 44.1%, respectively. Twelve months of cumulative survival in patients with Child-Pugh class A was 100%, class B was 50% and class C was 25% (log rank p = 0.002). Independent predictors of mortality at 12 months were lactate, bilirubin, PT ratio and age. The Child-Pugh + Lactate score was modified to produce an objective score comprising Albumin, Bilirubin and Clotting (PT ratio) added to serum lactate concentration in mmol L-1 (ABC + Lactate). This score was the best predictor of 12-month survival, with an AUC of 0.83. A proposed classification by ABC + Lactate score was highly significant (p = 0.001), with those in the highest class having ICU mortality of 75% and hospital and 12-month mortality of 93%.

CONCLUSIONS

Patients with cirrhosis admitted to ICU have high initial mortality but low mortality after hospital discharge. Child-Pugh class at ICU admission predicts outcome at 12 months. The ABC + Lactate classification system may be useful in identifying critically ill cirrhotic patients with very high long-term mortality.

Balanced haemostasis with both hypo- and hyper-coagulable features in critically ill patients with acute-on-chronic-liver failure

BACKGROUND

Cirrhotic patients have complex haemostatic abnormalities. Current evidence suggests stable cirrhotic (SC) patients have a "re-balanced" haemostatic state. However, limited data exists in acute decompensated (AD) or acute on chronic liver failure (ACLF) patients.

METHODS

We utilised thrombin generation analysis, fibrinolysis assessment, and evaluation of haemostatic parameters to assess haemostasis in liver disease of progressive severity.

RESULTS

The study cohorts were comprised of: SC, n=8; AD n=44; ACLF, n=17; and Healthy Control (HC), n=35. There was a progressive increase across the cohorts in INR (p=0.0001), Factor VIII (p=0.0001) and VWF levels (p=0.0001) and a correspondingly decrease in anti-thrombin (p=0.0001), ADAMTS-13 (p=0.01) and fibrinogen levels (p=0.0001). In the presence of thrombomodulin, thrombin generation was equivalent or significantly higher in all the cohorts compared to HC (p=0.0001). Compared to AD, ACLF had a lower ETP (p=0.002) and thrombin peak (p=0.0001). There was no significant difference across the cohorts in clot lysis time (p=0.07), although compared to HC, AD had a significantly shorter lysis time (p=0.001).

CONCLUSIONS

Our cohorts, despite significant differences in haemostatic parameters, displayed intact thrombin generation but progressive hypo-functional clot stability and potentially but not universal hyper-functional haemostasis.

Predicting mortality of patients with cirrhosis admitted to medical intensive care unit: An experience of a single tertiary center

BACKGROUND AND STUDY AIMS

Prognosis for patients with cirrhosis admitted to a medical intensive care unit (MICU) is poor and no previous studies have been published from Qatar or other countries in the region to investigate this issue. The objective of this study was to assess the predictors for in-hospital mortality and admission of cirrhotic patients to MICU in a single tertiary hospital in Qatar.

PATIENTS AND METHODS

All adult cirrhotic MICU patients hospitalized from 2007 through 2012 to Hamad General Hospital-Qatar were included. We compared them to cirrhotic patients admitted to medical wards during same period of time. All data were recorded and analyzed with respect to demographic parameters, clinical features and laboratory as well as radiology characteristics on day one of admission to MICU. Cirrhosis diagnosis was established either with a liver biopsy or the combination of physical, laboratory and radiologic findings. Predictors of mortality were defined by logistic regression analysis.

RESULTS

The cohort comprised 109 cirrhotic MICU patients (86.2% males), and their mean age±SD was 51.6±11.5. MICU-cirrhotic patients had longer hospital stays than medical wards-cirrhotic patients (p=0.01). Admission with severe hepatic encephalopathy, upper gastrointestinal bleeding and SOFA (Sepsis Related Organ Failure Assessment) score were the independent predicting factors for MICU admission. Mortality was higher for the MICU-cirrhotic group than medical wards group (27 (24.8%) deaths vs. 12 (5.3%) deaths, respectively, p=0.001). In multivariate logistic regression analyses, older age>60years (p=0.04), APACH-II score (p=0.001) and MELD score (p=0.02) were independent predicting factors for overall mortality.

CONCLUSION

Severe hepatic encephalopathy, upper gastrointestinal bleeding and SOFA score predict MICU admission of cirrhotic patients. Among MICU cirrhotic patients, older age, APACH-II score and MELD score predict mortality.

Prognosis of cirrhotic patients admitted to the general ICU

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.

Retrospective evaluation of prognostic score performances in cirrhotic patients admitted to an intermediate care unit

BACKGROUND

The prognosis of cirrhotic patients in the Intensive Care Unit requires the development of predictive tools for mortality. We aimed to evaluate the ability of different prognostic scores to predict hospital mortality in these patients.

METHODS

A single-centre retrospective analysis was conducted of 281 hospital stays of cirrhotic patients at an Intermediate Care Unit between June 2009 and December 2010. The performance of the Simplified Acute Physiology Score (SOFA), the Simplified Acute Physiology Score (SAPS) II or III, Child-Pugh, Model for End-Stage Liver Disease (MELD), MELD-Na and the Chronic Liver Failure-Consortium Acute-on-Chronic Liver Failure score (CLIF-C ACLF) in predicting hospital mortality were compared.

RESULTS

Mean age was 58.2±12.1 years; 77% were male. The main cause of admission was acute gastrointestinal bleeding (47%). The in-hospital mortality rate was 25.3%. Receiver operating characteristic curve analyses demonstrated that SOFA (0.82) MELD-Na (0.82) or MELD (0.81) scores at admission predicted in-hospital mortality better than Child-Pugh (0.76), SAPS II (0.77), SAPS III (0.75) or CLIF-C ACLF (0.75). We then developed the cirrhosis prognostic score (Ci-Pro), which performed better (0.89) than SOFA.

CONCLUSION

SOFA, MELD and especially the Ci-Pro score show the best performance in predicting hospital mortality of cirrhotic patients admitted to an Intermediate Care Unit.

Timing and causes of death in septic shock

Background

Most studies about septic shock report a crude mortality rate that neither distinguishes between early and late deaths nor addresses the direct causes of death. We herein aimed to determine the modalities of death in septic shock.

Methods

This was a 6-year (2008–2013) monocenter retrospective study. All consecutive patients diagnosed for septic shock within the first 48 h of intensive care unit (ICU) admission were included. Early and late deaths were defined as occurring within or after 3 days following ICU admission, respectively. The main cause of death in the ICU was determined from medical files. A multinomial logistic regression analysis using the status alive as the reference category was performed to identify the prognostic factors associated with early and late deaths.

Results

Five hundred forty-three patients were included, with a mean age of 66 ± 15 years and a high proportion (67 %) of comorbidities. The in-ICU and in-hospital mortality rates were 37.2 and 45 %, respectively. Deaths occurred early for 78 (32 %) and later on for 166 (68 %) patients in the ICU (n = 124) or in the hospital (n = 42). Early deaths were mainly attributable to intractable multiple organ failure related to the primary infection (82 %) and to mesenteric ischemia (6.4 %). In-ICU late deaths were directly related to end-of-life decisions in 29 % of patients and otherwise mostly related to ICU-acquired complications, including nosocomial infections (20.4 %) and mesenteric ischemia (16.6 %). Independent determinants of early death were age, malignancy, diabetes mellitus, no pathogen identification, and initial severity. Among 3-day survivors, independent risk factors for late death were age, cirrhosis, no pathogen identification, and previous corticosteroid treatment.

Conclusions

Our study provides a comprehensive assessment of septic shock-related deaths. Identification of risk factors of early and late deaths may determine differential prognostic patterns.

Appropriate and timely antimicrobial therapy in cirrhotic patients with spontaneous bacterial peritonitis-associated septic shock: a retrospective cohort study

BACKGROUND

Spontaneous bacterial peritonitis (SBP)-associated septic shock carries significant mortality in cirrhosis.

AIM

To determine whether practice-related aspects of antimicrobial therapy contribute to high mortality.

METHODS

Retrospective cohort study of all (n = 126) cirrhotics with spontaneous bacterial peritonitis (neutrophil count >250 or positive ascitic culture)-associated septic shock (1996-2011) from an international, multicenter database. Appropriate antimicrobial therapy implied either in vitro activity against a subsequently isolated pathogen (culture positive) or empiric management consistent with broadly accepted norms (culture negative).

RESULTS

Overall hospital mortality was 81.8%. Comparing survivors (n = 23) with non-survivors (n = 103), survivors had lower Acute Physiology and Chronic Health Evaluation (APACHEII) (mean ± s.d.; 22 ± 7 vs. 32 ± 8) and model for end-stage liver disease (MELD) (24 ± 9 vs. 34 ± 11) scores and serum lactate on admission (4.9 ± 3.1 vs. 8.9  ± 5.3), P < 0.001 for all. Survivors were less likely to receive inappropriate initial antimicrobial therapy (0% vs. 25%, P = 0.013) and received appropriate antimicrobial therapy earlier [median 1.8 (1.1-5.2) vs. 9.5 (3.9-14.3) h, P < 0.001]. After adjusting for covariates, APACHEII [OR, odds ratio 1.45 (1.04-2.02) per 1 unit increment, P = 0.03], lactate [OR 2.34 (1.04-5.29) per unit increment, P = 0.04] and time delay to appropriate antimicrobials [OR 1.86 (1.10-3.14) per hour increment, P = 0.02] were significantly associated with increased mortality.

CONCLUSIONS

Cirrhotic patients with septic shock secondary to spontaneous bacterial peritonitis have high mortality (>80%). Each hour of delay in appropriate antimicrobial therapy was associated with a 1.86 times increased hospital mortality. Admission APACHEII and serum lactate also significantly impacted hospital mortality. Earlier initiation of appropriate antimicrobial therapy could substantially improve outcome.

Advances in management and prognostication in critically ill cirrhotic patients

PURPOSE OF REVIEW

To provide an update on the recent publications for the management and prognostication of critically ill cirrhotic patients before and after liver transplant.

RECENT FINDINGS

The CLIF Acute-oN-ChrONicLIver Failure in Cirrhosis (CANONIC) study recently derived an evidence-based definition of acute-on-chronic liver failure (ACLF): hepatic decompensation; organ failure [predefined by the Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA)]; and high 28-day mortality rate. Although Sequential Organ Failure Assessment (SOFA) appears to be more accurate in predicting ICU and hospital mortality in ACLF patients, CLIF-SOFA has been derived specifically for critically ill cirrhotic patients, including those not receiving mechanical ventilation. Recent data suggest that a lower transfusion target in esophageal variceal bleeding (<7 g/l) is safe. Newly defined 'cirrhosis-associated acute kidney injury (AKI)' correlates with mortality, organ failure and length of hospital stay. Although the SOFA score appears to perform better than liver-specific scoring systems [Model for End-stage Liver Disease (MELD) and Child-Pugh scores], neither MELD nor SOFA appears to independently predict posttransplant survival; however, correlated with lengths of ICU and hospital stay. For patients declined for liver transplant, palliative care referral and appropriate goals of care are rarely achieved.

SUMMARY

New definitions for ACLF, cirrhosis-associated AKI and the CLIF-SOFA may improve the discrimination between survivors and nonsurvivors with ACLF. Predicting futility postliver transplant based on preliver transplant severity of illness still poses significant challenges.

Improved prognosis of septic shock in patients with cirrhosis: a multicenter study*

OBJECTIVE

To determine the evolution of the outcome of patients with cirrhosis and septic shock.

DESIGN

A 13-year (1998-2010) multicenter retrospective cohort study of prospectively collected data.

SETTING

The Collège des Utilisateurs des Bases des données en Réanimation (CUB-Réa) database recording data related to admissions in 32 ICUs in Paris area.

PATIENTS

Thirty-one thousand two hundred fifty-one patients with septic shock were analyzed; 2,383 (7.6%) had cirrhosis.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Compared with noncirrhotic patients, patients with cirrhosis had higher Simplified Acute Physiology Score II (63.1 ± 22.7 vs 58.5 ± 22.8, p < 0.0001) and higher prevalence of renal (71.5% vs 54.8%, p < 0.0001) and neurological (26.1% vs 19.5%, p < 0.0001) dysfunctions. Over the study period, in-ICU and in-hospital mortality was higher in patients with cirrhosis (70.1% and 74.5%) compared with noncirrhotic patients (48.3% and 51.7%, p < 0.0001 for both comparisons). Cirrhosis was independently associated with an increased risk of death in ICU (adjusted odds ratio = 2.524 [2.279-2.795]). In patients with cirrhosis, factors independently associated with in-ICU mortality were as follows: admission for a medical reason, Simplified Acute Physiology Score II, mechanical ventilation, renal replacement therapy, spontaneous bacterial peritonitis, positive blood culture, and infection by fungus, whereas direct admission and admission during the most recent midterm period (2004-2010) were associated with a decreased risk of death. From 1998 to 2010, prevalence of septic shock in patients with cirrhosis increased from 8.64 to 15.67 per 1,000 admissions to ICU (p < 0.0001) and their in-ICU mortality decreased from 73.8% to 65.5% (p = 0.01) despite increasing Simplified Acute Physiology Score II. In-ICU mortality decreased from 84.7% to 68.5% for those patients placed under mechanical ventilation (p = 0.004) and from 91.2% to 78.4% for those who received renal replacement therapy (p = 0.04).

CONCLUSIONS

The outcome of patients with cirrhosis and septic shock has markedly improved over time, akin to the noncirrhotic population. In 2010, the in-ICU survival rate was 35%, which now fully justifies to admit these patients to ICU.

The utility of scoring systems in critically ill cirrhotic patients admitted to a general intensive care unit

PURPOSE

This study aimed to establish which prognostic scoring tool provides the greatest discriminative ability when assessing critically ill cirrhotic patients in a general intensive care unit (ICU) setting.

METHODS

This was a 12-month, single-centered prospective cohort study performed in a general, nontransplant ICU. Forty clinical and demographic variables were collected on admission to calculate 8 prospective scoring tools. Patients were followed up to obtain ICU and inhospital mortality. Receiver operating characteristic curve analysis was used to determine the discriminative ability of the scores. Univariate and multivariate analyses were used to identify any independent predictors of mortality in these patients. The incorporation of any significant variables into the scoring tools was assessed.

RESULTS

Fifty-nine cirrhotic patients were admitted over the study period, with an ICU mortality of 31%. All scores other than the renal-specific Acute Kidney Injury Network score had similar discriminative abilities, producing area under the curves of between 0.70 and 0.76. None reached the clinically applicable level of 0.8. The Sequential Organ Failure Assessment score was the best performing score. Lactate and ascites were individual predictors of ICU mortality with statistically significant odds ratios of 1.69 and 5.91, respectively. When lactate was incorporated into the Child-Pugh score, its prognostic accuracy increased to a clinically applicable level (area under the curve, 0.86).

CONCLUSIONS

This investigation suggests that established prognostic scoring systems should be used with caution when applied to the general, nontransplant ICU as compared to specialist centers. Our data suggest that serum arterial lactate may improve the prognostic ability of these scores.

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

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 χ(2) 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 χ(2) 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 χ(2) 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.

Outcome of patients with cirrhosis requiring mechanical ventilation in ICU

INTRODUCTION

Mortality rate of patients with cirrhosis admitted to the intensive care unit (ICU) and requiring mechanical ventilation varies between 60 and 91%. The aim of our study is to assess the prognosis of these patients, their 1-year outcome and to analyze predictive factors of long-term mortality.

METHODS

From May 2005 to May 2011, we studied 246 consecutive patients with cirrhosis requiring mechanical ventilation either at admission or during their ICU stay.

RESULTS

Alcohol was the most common etiology of the cirrhosis (69%). Bleeding related to portal hypertension (30%) and severe sepsis (33%) were the most common reasons for admission. ICU and hospital mortality were respectively 65.9% and 70.3%. Prognostic severity scores, the need for other organ support therapy, infection, and total bilirubin value at ICU admission were significantly associated with ICU mortality. Eighty-four patients (34.1%) were discharged from the ICU. Among these patients, the one-year survival was only of 32%. Logistic regression analysis, using survival at one year as the endpoint, identified two independent risk factors: the length of ventilation (odds ratio [OR] = 1.1; 95% CI, 1.0-1.2; p = 0.02) and total bilirubin at ICU discharge (OR = 1.3; 95% CI, 1.1-1.5; p = 0.006).

CONCLUSION

Patients with cirrhosis admitted to the liver ICU and who required mechanical ventilation have a poor prognosis with a 1-year mortality of 89%. At ICU discharge, a total bilirubin level higher than 64.5 μmol/L and length of ventilation higher than 9 days could help the hepatologists to identify patients at risk of death in the year following the ICU discharge.

Prognostic scores for cirrhotic patients admitted to an intensive care unit: which consequences for liver transplantation?

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 liver-specific 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 cut-off levels based on mortality prediction. The CLIF-SOFA could represent the ideal score in ICU since it is based on organ failures with cut-off 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.

Factors that predict short-term intensive care unit mortality in patients with cirrhosis

BACKGROUND & AIMS

Despite advances in critical care medicine, the mortality rate is high among critically ill patients with cirrhosis. We aimed to identify factors that predict early (7 d) mortality among patients with cirrhosis admitted to the intensive care unit (ICU) and to develop a risk-stratification model.

METHODS

We collected data from patients with cirrhosis admitted to the ICU at Indiana University (IU-ICU) from December 1, 2006, through December 31, 2009 (n = 185), or at the University of Pennsylvania (Penn-ICU) from May 1, 2005, through December 31, 2010 (n = 206). Factors associated with mortality within 7 days of admission (7-d mortality) were determined by logistic regression analyses. A model was constructed based on the predictive parameters available on the first day of ICU admission in the IU-ICU cohort and then validated in the Penn-ICU cohort.

RESULTS

Median Model for End-stage Liver Disease (MELD) scores at ICU admission were 25 in the IU-ICU cohort (interquartile range, 23-34) and 32 in the Penn-ICU cohort (interquartile range, 26-41); corresponding 7-day mortalities were 28.3% and 53.6%, respectively. MELD score (odds ratio, 1.13; 95% confidence interval [CI], 1.07-1.2) and mechanical ventilation (odds ratio, 5.7; 95% CI, 2.3-14.1) were associated independently with 7-day mortality in the IU-ICU. A model based on these 2 variables separated IU-ICU patients into low-, medium-, and high-risk groups; these groups had 7-day mortalities of 9%, 27%, and 74%, respectively (concordance index, 0.80; 95% CI, 0.72-0.87; P < 10(-8)). The model was applied to the Penn-ICU cohort; the low-, medium-, and high-risk groups had 7-day mortalities of 33%, 56%, and 71%, respectively (concordance index, 0.67; 95% CI, 0.59-0.74; P < 10(-4)).

CONCLUSIONS

A model based on MELD score and mechanical ventilation on day 1 can stratify risk of early mortality in patients with cirrhosis admitted to the ICU. More studies are needed to validate this model and to enhance its clinical utility.

Increased survival of cirrhotic patients with septic shock

Introduction

The overall outcome of septic shock has been recently improved. We sought to determine whether this survival gain extends to the high-risk subgroup of patients with cirrhosis.

Methods

Cirrhotic patients with septic shock admitted to a medical intensive care unit (ICU) during two consecutive periods (1997-2004 and 2005-2010) were retrospectively studied.

Results

Forty-seven and 42 cirrhotic patients presented with septic shock in 1997-2004 and 2005-2010, respectively. The recent period differed from the previous one by implementation of adjuvant treatments of septic shock including albumin infusion as fluid volume therapy, low-dose glucocorticoids, and intensive insulin therapy. ICU and hospital survival markedly improved over time (40% in 2005-2010 vs. 17% in 1997-2004, P = 0.02 and 29% in 2005-2010 vs. 6% in 1997-2004, P = 0.009, respectively). Furthermore, this survival gain in the latter period was sustained for 6 months (survival rate 24% in 2005-2010 vs. 6% in 1997-2004, P = 0.06). After adjustment with age, the liver disease stage (Child-Pugh score), and the critical illness severity score (SOFA score), ICU admission between 2005 and 2010 remained an independent favorable prognostic factor (odds ratio (OR) 0.09, 95% confidence interval (CI) 0.02-0.4, P = 0.004). The stage of the underlying liver disease was also independently associated with hospital mortality (Child-Pugh score: OR 1.42 per point, 95% CI 1.06-1.9, P = 0.018).

Conclusions

In the light of advances in management of both cirrhosis and septic shock, survival of such patients substantially increased over recent years. The stage of the underlying liver disease and the related therapeutic options should be included in the decision-making process for ICU admission.