Increased Survival for Patients With Cirrhosis and Organ Failure in Liver Intensive Care and Validation of the Chronic Liver Failure–Sequential Organ Failure Scoring System

doi:10.1016/j.cgh.2014.08.041

Clinical Gastroenterology and Hepatology

Volume 13, Issue 7, July 2015, Pages 1353-1360.e8

https://doi.org/10.1016/j.cgh.2014.08.041 Get rights and content

Background & Aims

During the past decade, survival has increased among patients admitted to general intensive care units, but it is not clear if it has increased for patients admitted with cirrhosis and organ failure. The chronic liver failure–sequential organ failure assessment (CLIF-SOFA) recently was developed as an adaptation to the SOFA to predict outcomes of patients, but requires validation. We investigated changes in outcomes of patients with cirrhosis and organ failure since 2000, compared the abilities of SOFA and CLIF-SOFA to predict patient survival, and validated the CLIF-SOFA system.

Methods

In a retrospective study, we collected data from 971 patients (median age, 52 y; age range, 16–90 y; 62% male) with cirrhosis (54% alcohol associated, 12% viral, and 34% other causes). The patients were admitted under emergency conditions from January 1, 2000, to December 31, 2010, to a liver intensive therapy unit in the United Kingdom. Patient survival while in the hospital was compared with measures of illness severity, Acute Physiology and Chronic Health Evaluation (APACHE) II scores, model for end-stage liver disease (MELD) scores, SOFA scores, and CLIF-SOFA scores.

Results

Patients had a median APACHE II score of 21 (range, 5–50) and a median MELD score of 23 (range, 6–40). The median APACHE II score at admission decreased from 23 to 22 over the study period (P < .001), whereas the median MELD score at admission decreased from 23 to 18 (P < .001). Overall survival until hospital discharge was 51%; this value increased from 40% in 2000 to 63% in 2010 (P < .001). The unadjusted odds ratio for change in mortality/year was 0.87 (95% confidence interval, 0.83–0.91; P < .001). The APACHE II score adjusted odds ratio for mortality was 0.89 (95% confidence interval, 0.84–0.93; P < .001). The etiology of cirrhosis was not associated with a significant difference in survival. CLIF-SOFA and SOFA scores at the time of admission predicted patient survival with area under the receiver operating curve (AUROC) values of 0.813 and 0.799, respectively; the scores at 48 hours after admission predicted survival with AUROC values of 0.853 and 0.840, and scores after 1 week predicted survival with AUROC values of 0.842 and 0.844, respectively. These AUROC values were higher than those obtained from APACHE II or MELD scores.

Conclusions

The proportion of patients with cirrhosis who survived after admission to intensive care increased from 2000 to 2010. SOFA and CLIF-SOFA scores during the first week of critical care appear to have similar abilities to predict patient survival.

Section snippets

Methods

Between January 2000 and December 2010 consecutive admissions to the liver intensive therapy unit (LITU) at King’s College Hospital had prospective predefined capture of baseline demographic and clinical data by dedicated auditors. The worst result/score in the 24-hour period was used for that day's result. These data were collected daily for the total critical care admission period. Detailed LITU discharge documents were produced by senior medical staff and also were used as a data source.

Cohort Characteristics

A total of 1032 patients originally were identified. After exclusions, 971 patients with an underlying diagnosis of cirrhosis were admitted during the period beginning from 2000 to the end of 2011, and formed the basis of the study cohort (Table 1).

The median age was 51 years (range, 16–90 y), with a male:female sex profile of 615:356 (63%:37%). There was no survival difference between men and women and no difference in median admission APACHE II score (P = .548). The median admission MELD

Discussion

We have shown that in more than a decade of experience in treating patients with cirrhosis requiring organ support, clinically meaningful and statistically significant improvements in outcome have occurred. In this cohort even patients with 2 or 3 organs in failure at admission still had 30% to 55% survival rates, although the mortality rate in patients with more than 3 organs in failure at admission approached 80%.

We found that alcohol was not an etiology that was associated with worse

Acknowledgments

All authors are grateful to the National Institute for Health Research biomedical research council at King's College London for infrastructure support during the course of this study. Mark McPhail also thanks the National Institute for Health Research biomedical research center at Imperial College London for infrastructure support during this study.

References (20)

A. Aggarwal et al.
Predictors of mortality and resource utilization in cirrhotic patients admitted to the medical ICU
Chest
(2001)
D.L. Shawcross et al.
The impact of organ dysfunction in cirrhosis: survival at a cost?
J Hepatol
(2012)
E. Levesque et al.
Prospective evaluation of the prognostic scores for cirrhotic patients admitted to an intensive care unit
J Hepatol
(2012)
P.S. Kamath et al.
A model to predict survival in patients with end-stage liver disease
Hepatology
(2001)
R. Bahirwani et al.
Factors that predict short-term intensive care unit mortality in patients with cirrhosis
Clin Gastroenterol Hepatol
(2013)
S.J. Thomson et al.
Chronic liver disease–an increasing problem: a study of hospital admission and mortality rates in England, 1979–2005, with particular reference to alcoholic liver disease
Alcohol Alcohol
(2008)
S.E. Roberts et al.
Trends in mortality after hospital admission for liver cirrhosis in an English population from 1968 to 1999
Gut
(2005)
V. Das et al.
Cirrhotic patients in the medical intensive care unit: early prognosis and long-term survival
Crit Care Med
(2010)
Y. Arabi et al.
Outcome predictors of cirrhosis patients admitted to the intensive care unit
Eur J Gastroenterol Hepatol
(2004)
E. Cholongitas et al.
Risk factors, sequential organ failure assessment and model for end-stage liver disease scores for predicting short term mortality in cirrhotic patients admitted to intensive care unit
Aliment Pharmacol Ther
(2006)

There are more references available in the full text version of this article.

Cited by (89)

EASL Clinical Practice Guidelines on the management of hepatic encephalopathy
2022, Journal of Hepatology
The EASL Clinical Practice Guidelines (CPGs) on the management of hepatic encephalopathy (HE) present evidence-based answers to a set of relevant questions (where possible, formulated in PICO [patient/population, intervention, comparison and outcomes] format) on the definition, diagnosis, differential diagnosis and treatment of HE. The document does not cover the pathophysiology of HE and does not cover all available treatment options. The methods through which it was developed and any information relevant to its interpretation are also provided.
Relationship Between Etiology of Cirrhosis and Survival Among Patients Hospitalized in Intensive Care Units
2022, Mayo Clinic Proceedings
To determine short-term outcomes of patients with alcohol-associated cirrhosis (ALC) admitted to the intensive care unit (ICU) compared with other etiologies of liver disease. In addition, we investigate whether quick sequential organ failure assessment accurately predicts presence of sepsis and in-hospital mortality in critically ill patients with various etiologies of cirrhosis.
A retrospective cohort of 1174 consecutive patients with cirrhosis admitted to the ICU between January of 2006 and December of 2015 was analyzed. Outcomes of interest included survival rates within the ICU, post-ICU in-hospital, or at 30 days post-ICU discharge.
Five hundred seventy-eight patients were found to have ALC with 596 in the non-ALC group. There was no significant difference in ICU mortality rates in ALC versus non-ALC cohorts (10.2% vs 11.7%, P=.40). However, patients with ALC had significantly higher post-ICU in-hospital death (10.0% vs 6.5%, P=.04) as well as higher mortality at 30-day post-ICU discharge (18.7% vs 11.2%, P<.001). Sustained alcohol abstinence did not offer survival advantage over nonabstinence. The predictive power for quick sequential organ failure assessment for sepsis and in-hospital mortality for patients with cirrhosis was limited.
Critically ill patients with ALC have decreased survival after ICU discharge compared with patients with other etiologies of cirrhosis, independent of alcohol abstinence.
Management of Decompensated Cirrhosis and Associated Syndromes
2022, Surgical Clinics of North America
Intensive care management of acute-on-chronic liver failure
2021, Journal of Hepatology
The syndrome of acute-on-chronic liver failure combines deterioration of liver function in a patient with chronic liver disease, with the development of extrahepatic organ failure and high short-term mortality. Its successful management demands a rapid and coherent response to the development of dysfunction and failure of multiple organ systems in an intensive care unit setting. This response recognises the features that distinguish it from other critical illness and addresses the complex interplay between the precipitating insult, the many organ systems involved and the disordered physiology of underlying chronic liver disease. An evidence base is building to support the approaches currently adopted and outcomes for patients with this condition are improving, but mortality remains unacceptably high. Herein, we review practical considerations in critical care management, as well as discussing key knowledge gaps and areas of controversy that require further focussed research.
Management of liver failure in general intensive care unit
2020, Anaesthesia Critical Care and Pain Medicine
To produce French guidelines on Management of Liver failure in general Intensive Care Unit (ICU).
A consensus committee of 23 experts from the French Society of Anesthesiology and Critical Care Medicine (Société française d’anesthésie et de réanimation, SFAR) and the French Association for the Study of the Liver (Association française pour l’étude du foie, AFEF) was convened. A formal conflict-of-interest (COI) policy was developed at the start of the process and enforced throughout. The entire guideline process was conducted independently of any industrial funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide their assessment of the quality of evidence. The potential drawbacks of making strong recommendations in the presence of low-quality evidence were emphasised. Some recommendations were ungraded.
Two fields were defined: acute liver failure (ALF) and cirrhotic patients in general ICU. The panel focused on three questions with respect to ALF: (1) Which etiological examinations should be performed to reduce morbidity and mortality? (2) Which specific treatments should be initiated rapidly to reduce morbidity and mortality? (3) Which symptomatic treatment should be initiated rapidly to reduce morbidity and mortality? Seven questions concerning cirrhotic patients were addressed: (1) Which criteria should be used to guide ICU admission of cirrhotic patients in order to improve their prognosis? (2) Which specific management of kidney injury should be implemented to reduce morbidity and mortality in cirrhotic ICU patients? (3) Which specific measures to manage sepsis in order to reduce morbidity and mortality in cirrhotic ICU patients? (4) In which circumstances, human serum albumin should be administered to reduce morbidity and mortality in cirrhotic ICU patients? (5) How should digestive haemorrhage be treated in order to reduce morbidity and mortality in cirrhotic ICU patients? (6) How should haemostasis be managed in order to reduce morbidity and mortality in cirrhotic ICU patients? And (7) When should advice be obtained from an expert centre in order to reduce morbidity and mortality in cirrhotic ICU patients? Population, intervention, comparison and outcome (PICO) issues were reviewed and updated as required, and evidence profiles were generated. An analysis of the literature and recommendations was then performed in accordance with the GRADE® methodology.
The SFAR/AFEF Guidelines panel produced 18 statements on liver failure in general ICU. After two rounds of debate and various amendments, a strong agreement was reached on 100% of the recommendations: six had a high level of evidence (Grade 1 ±), seven had a low level of evidence (Grade 2 ±) and six were expert judgments. Finally, no recommendation was provided with respect to one question.
Substantial agreement exists among experts regarding numerous strong recommendations on the optimum care of patients with liver failure in general ICU.
Cirrhotic cardiomyopathy influences clinical outcomes and enhances performance of conventional risk prediction models in acute-on-chronic liver failure with severe sepsis
2023, Alimentary Pharmacology and Therapeutics

View all citing articles on Scopus

: Conflicts of interest The authors disclose no conflicts.

: Funding Supported by the Wellcome Trust (grant number ME047380MES), United Kingdom, a postdoctoral training fellowship during this study (M.J.W.M.), a doctoral studentship from the National Institute for Health Research (R.D.A.), and by a Higher Education Funding Council for England National Institute for Health Research senior lectureship (D.L.S.).

View full text

Original articlePancreas, biliary tract, and liverIncreased Survival for Patients With Cirrhosis and Organ Failure in Liver Intensive Care and Validation of the Chronic Liver Failure–Sequential Organ Failure Scoring System

Background & Aims

Methods

Results

Conclusions

Section snippets

Methods

Cohort Characteristics

Discussion

Acknowledgments

Chest

J Hepatol

J Hepatol

Hepatology

Clin Gastroenterol Hepatol

Chronic liver disease–an increasing problem: a study of hospital admission and mortality rates in England, 1979–2005, with particular reference to alcoholic liver disease

Alcohol Alcohol

Trends in mortality after hospital admission for liver cirrhosis in an English population from 1968 to 1999

Gut

Cirrhotic patients in the medical intensive care unit: early prognosis and long-term survival

Crit Care Med

Outcome predictors of cirrhosis patients admitted to the intensive care unit

Eur J Gastroenterol Hepatol

Risk factors, sequential organ failure assessment and model for end-stage liver disease scores for predicting short term mortality in cirrhotic patients admitted to intensive care unit

Aliment Pharmacol Ther

Original article
Pancreas, biliary tract, and liver
Increased Survival for Patients With Cirrhosis and Organ Failure in Liver Intensive Care and Validation of the Chronic Liver Failure–Sequential Organ Failure Scoring System