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

Karvellas, Constantine J.; García-López, E.; Fernández, Javier; Saliba, Faouzi; Sy, Eric; Jalan, Rajiv; Pavesi, Marco; Gustot, Thierry; Ronco, Juan J.; Arroyo, Vicente

doi:10.1097/ccm.0000000000003369

Cited by 51 publications

(42 citation statements)

References 36 publications

(23 reference statements)

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“…This allows earlier engagement with the ICU and liver transplantation teams, resulting in an increase in the total number of ICU admissions, yet a reduction in mortality (see Table for an assessment of the cost of ACLF to the US economy in comparison with other serious illnesses). In contrast, new thresholds for futility of ongoing ICU care for patients with ACLF have been identified, to permit the release of precious ICU beds with the hope that patients and relatives will not be unduly distressed …”

Section: Impact Of Recognition Of Aclf As a New Syndromementioning

confidence: 99%

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Acute‐on‐Chronic Liver Failure: A New Disease or an Old One Hiding in Plain Sight?

Jalan

Moreau

Arroyo

et al. 2020

Clinical Liver Disease

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Section: Impact Of Recognition Of Aclf As a New Syndromementioning

confidence: 99%

“…In contrast, new thresholds for futility of ongoing ICU care for patients with ACLF have been identified, to permit the release of precious ICU beds with the hope that patients and relatives will not be unduly distressed. [16][17][18]…”

Section: Impact On the Economymentioning

confidence: 99%

Acute‐on‐Chronic Liver Failure: A New Disease or an Old One Hiding in Plain Sight?

Jalan

Moreau

Arroyo

et al. 2020

Clinical Liver Disease

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“…Requirements for vasopressors and mechanical ventilation were identified as the failures associated with the worst outcomes in some studies 32,48,50 whereas this was not reported in a large recent international study. 40 Liver failure, as defined by a total bilirubin ≥ 12 mg/dl in the CANONIC study, was an independent predictor of a severe lifethreatening course of ACLF, suggesting a central role as a trigger or perpetuating factor of multiorgan failure. 29…”

Section: Key Pointsmentioning

confidence: 84%

“…In this work, CLIF-C ACLF failed to show better perfomance in prediction of 90 days mortality compared to MELD (AUROC 0.68 vs. 0.67, p=0.3). 39,40 Moreover, its daily use seems less convenient than the evaluation of OF number by the CLIF-C OF. Lactate levels were independently associated with short-term mortality in critically ill patients with liver cirrhosis and were shown to significantly improve performance of CLIF-C ACLF.…”

Section: Key Pointsmentioning

confidence: 99%

Approaches for patients with very high MELD scores

Artru

Samuel

2019

JHEP Reports

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In the era of the "sickest first" policy, patients with very high model for end-stage liver disease (MELD) scores have been increasingly admitted to the intensive care unit with the expectation that they will receive a liver transplant (LT) in the absence of improvement on supportive therapies. Such patients are often admitted in a context of acute-on-chronic liver failure with extrahepatic failures. Sequential assessment of scores or classification based on organ failures within the first days after admission help to stratify the risk of mortality in this population. Although the prognosis of severely ill cirrhotic patients has recently improved, transplant-free mortality remains high. LT is still the only curative treatment in this population. Yet, the increased relative scarcity of graft resource must be considered alongside the increased risk of losing a graft in the initial postoperative period when performing LT in "too sick to transplant" patients. Variables associated with poor immediate post-LT outcomes have been identified in large studies. Despite this, the performance of scores based on these variables is still insufficient. Consideration of a patient's comorbidities and frailty is an appealing predictive approach in this population that has proven of great value in many other diseases. So far, local expertise remains the last safeguard to LT. Using this expertise, data are accumulating on favourable post-LT outcomes in very high MELD populations, particularly when LT is performed in a situation of stabilization/improvement of organ failures in selected candidates. The absence of "definitive" contraindications and the control of "dynamic" contraindications allow a "transplantation window" to be defined. This window must be identified swiftly after admission given the poor short-term survival of patients with very high MELD scores. In the absence of any prospect of LT, withdrawal of care could be discussed to ensure respect of patient life, dignity and wishes.

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“…We found similar C‐statistics for the CLIF‐C ACLF score in our cohort, ranging from 0.74 to 0.78. In a separate study of academic Canadian hospitals, the CLIF‐C ACLF score was also used to predict short‐term mortality in 867 ACLF patients admitted to the ICU . This yielded C‐statistics of 0.69 and 0.68 for 28 and 90‐day mortality respectively.…”

Section: Discussionmentioning

confidence: 99%

Risk prediction scores for acute on chronic liver failure development and mortality

Mahmud

Hubbard

Kaplan

et al. 2019

Liver International

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Background & Aims: Acute on chronic liver failure (ACLF) causes high short-term mortality in patients with previously stable chronic liver disease. To date there are no models to predict which patients are likely to develop ACLF, and existing models to predict ACLF mortality are based on limited cohorts. We sought to create novel risk prediction scores using a large cohort of patients with cirrhosis. Methods:We performed a retrospective cohort study of 74 790 patients with incident cirrhosis in the Veterans Health Administration database using randomized 70% derivation/30% validation sets. ACLF events were identified per the European ACLF criteria. Multivariable logistic regression was used to derive prediction models for developing ACLF at 3, 6 and 12 months, and ACLF mortality at 28 and 90 days. Mortality models were compared to model for end-stage liver disease (MELD), MELD-sodium and the Chronic Liver Failure Consortium (CLIF-C) ACLF score.Results: Models for the developing ACLF had very good discrimination (concordance [C] statistics 0.83-0.87) at all timepoints. Models for ACLF mortality also had good discrimination at 28 and 90 days (C-statistics 0.79-0.82), and were superior to MELD, MELD-sodium and the CLIF-C ACLF score. The calibration of the novel models was excellent at all timepoints.

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

Cited by 51 publications

References 36 publications

Acute‐on‐Chronic Liver Failure: A New Disease or an Old One Hiding in Plain Sight?

Acute‐on‐Chronic Liver Failure: A New Disease or an Old One Hiding in Plain Sight?

Approaches for patients with very high MELD scores

Risk prediction scores for acute on chronic liver failure development and mortality

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