Short-term prognosis in critically ill patients with cirrhosis assessed by prognostic scoring systems

Abstract

The short-term prognosis of acutely ill patients with cirrhosis is influenced by the degree of hepatic insufficiency and by dysfunction of extrahepatic organ systems. The purpose of this study was to assess and compare the prognostic accuracy of the Child-Pugh classification, the Acute Physiology and Chronic Health Evaluation (APACHE) II system and the Sequential Organ Failure Assessment (SOFA) for predicting hospital mortality in patients with cirrhosis when used 24 hours after admission to a medical intensive care unit (ICU). Prospective data were recorded on 143 patients. Cumulative mortality rates were 36% in the ICU, 46% in the hospital, and 56% at 6-month follow-up. By using the area under receiver operating characteristic (AUROC) curves, the SOFA showed an excellent discriminative power (AU-ROC 0.94), which was clearly superior to the APACHE II (AUROC 0.79) and the Child-Pugh system (AUROC 0.74). Hospital mortality rates below and above a cutoff of 8 SOFA points were 4% and 88%, respectively (P < .0005). The SOFA score also reflected resource use during the ICU treatment as measured by daily workload and length of stay. The SOFA is an easily applied tool with excellent prognostic abilities and can be used to enhance clinical judgment of prognosis as well as providing patients and families with objective information. (HEPATOLOGY 2001;34:255-261.)

Prognostic scores in cirrhotic patients admitted to a gastroenterology intensive care unit

“…less sick patients. Indeed, although APACHE II works well for severely ill cirrhotic patients admitted to ICUs (13,17,29,(36)(37)(38), this is not the case when its predictive value is assessed in a population of cirrhotic patients with mortality rate of only 11.5% (41). Thus, our results are somewhat surprising, because the mortality rate in our sample was only 9.7% and nevertheless the scores showed an excellent performance.…”

“…These findings support the importance of evaluating the performance of a predictive model not only in terms of its discriminative capacity but also its calibration. If, as in some studies (13,17,36,38), we had based the evaluation on discriminative ability alone, we would say that the SAPS II and CPT scores had the best performance. Nevertheless, we found that the best calibration results were obtained by the SOFA and MELD scores.…”

“…These results were somewhat expected if we take into account the characteristics of the cirrhotic patients admitted to ICUs and the structure of the different scores. Regarding the characteristics of the cirrhotics admitted to ICUs, these patients often have extrahepatic organ dysfunction and die of multiple organ failure (12)(13)(14)(34)(35)(36)(37)(38)(39). Concerning the structure of the prognostic models, the general scores include a global assessment of the patient's clinical condition, evaluating parameters related to the various organ systems (20)(21)(22)(23).…”

“…These results are somewhat unsurprising if we bear in mind that the prognosis of acutely ill patients with cirrhosis is influenced not only by the severity of hepatic insufficiency but mainly by the dysfunction of other organ systems and that cirrhotics admitted to ICUs often have extrahepatic organ dysfunction and die of multiple organ failure (12)(13)(14)(34)(35)(36)(37)(38)(39).…”

Extracorporeal liver support

“…42,43 Under these circumstances, supporting failing liver function for a short period of time while correcting the precipitating event might help patients recover or be successfully be bridged to liver transplantation. 44 Currently, the Molecular Adsorbent Recirculating System (MARS ® ) is the only extracorporeal liver support device that has proven to be effective in improving severe (grade 3 and 4) hepatic encephalopathy by a prospective randomized multi-center study. 45 In short, patients with end stage chronic liver disease (MELD score around 30, CTP score above 10) and intractable severe coma (HE grade 3 and 4, Glasgow Coma Scale around 7) who did not respond to prior conventional therapy were randomized to either additional daily MARS ® therapy or continuation of standard therapy only.…”