Factors That Predict Short-term Intensive Care Unit Mortality in Patients With Cirrhosis

Abstract

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.

The confusion assessment method for the intensive care unit in patients with cirrhosis

“…Such referral patterns likely result in a selection bias where Indiana University Hospital provides care for more of the sicker patients, leaving a comparatively “healthy” population of individuals with cirrhosis at WMH. Indeed, MELD and mortality in this study were substantially less than in other similar cohorts (Bahirwani et al 2013). Therefore, this study's findings need to be generalized to sicker populations in future studies.…”

“…Mortality in patients with cirrhosis in the ICU has been examined in several recently published studies. Increased mortality has been associated with several factors including liver-specific measures such as MELD (and its components) and Child-Pugh, and general ICU measures such as Sequential Organ Failure Assessment, APACHE II, and the need for mechanical ventilation (Bahirwani et al 2013; Cavallazzi et al 2012; Cholongitas et al 2012; Filloux et al 2010; Levesque et al 2012; Tu et al 2011). In addition to these liver-specific and general ICU measures of disease severity, this study demonstrates that formal delirium assessment may have additional prognostic value.…”

Early post-transplant survival: Interaction of MELD score and hospitalization status

“…in practice a death at 4 versus 5 months are the same). 14–16 Additionally, the binary outcomes allowed for appropriate analytic models that accounted for correlation of patient outcomes due to clustering within transplant centers. 17–19 Post-transplant deaths included transplant recipients with the post-transplant status code of “died,” or those without this code, but a confirmed Social Security Death Master File (SSDMF) death date in the OPTN/UNOS dataset, within the specified time period.…”

“…Covariates evaluated for inclusion in the final model were those either independently associated with post-transplant mortality in previous studies 14–16 or variables included in the Scientific Registry of Transplant Recipients (SRTR) risk-adjusted models for center-specific outcomes 21 : recipient age, race/ethnicity, sex, albumin at transplant, laboratory MELD score at transplant, pre-transplant hospitalization status, functional status, mechanical ventilation, life support, dialysis, and primary diagnosis. Functional status was defined according to the following Karnofsky score classification: moderate to severe impairment (Karnofsky score of 10–40%), mild impairment (50–70%) and no impairment (80–100%).…”

Outcomes After Listing for Liver Transplant in Patients With Acute‐on‐Chronic Liver Failure: The Multicenter North American Consortium for the Study of End‐Stage Liver Disease Experience

“…If patients are transplanted after developing ACLF, most data show either a numerical increase or statistically significant increase in mortality after LT . When the European Association for the Study of the Liver (EASL)–chronic liver failure (CLIF) grading for ACLF was used, a marked difference in outcome was observed in patients after LT depending on the severity of ACLF: ACLF grade 1 and 2 had acceptable post‐LT outcomes, whereas ACLF grade 3 had unacceptable post‐LT outcomes .…”