Reply to: “Patients with cirrhosis admitted to an Intensive Care Unit”
Authors: Eric Levesque, Faouzi Saliba, Didier Samuel
Journal: Journal of Hepatology (2012)

Patients with cirrhosis admitted to an Intensive Care UnitJournal of HepatologyVol. 57Issue 1PreviewWe read with great interest the study by Levesque et al. [1], recently published in the Journal of Hepatology, regarding the prognostic ability of ICU-specific scores, such as SOFA score, and liver-specific scores [Child-Pugh (CTP), standard MELD, and MELD-serum sodium scores] in 377 patients with cirrhosis admitted to their intensive care unit (ICU). As the authors mentioned, their study are in accordance with our systematic review [2] that general ICU prognostic models are superior to the CTP score in cirrhotics with acute deterioration of chronic liver disease, and they confirmed our previous study [3], which showed that the SOFA score had better discriminative accuracy for mortality, compared to the MELD score. Full-Text PDF Open AccessProspective evaluation of the prognostic scores for cirrhotic patients admitted to an Intensive Care UnitJournal of HepatologyVol. 56Issue 1PreviewCirrhotic patients admitted to an Intensive Care Unit (ICU) have a poor prognosis. Identifying patients in whom ICU care will be useful can be challenging. The aim of this study was to assess the predictive value of prognostic scores with respect to mortality and to identify mortality risk factors. Full-Text PDF We thank Dr. Cholongitas and colleagues for their comments on our paper on the prognostic score for cirrhotic patients admitted to an Intensive Care Unit (ICU) and for sharing their experience. Consistent with previous studies in critical care, these two large series (our study with 377 patients and the evaluation of Cholongitas et al. with 412 patients) showed that the prognosis of patients with cirrhosis admitted to the ICU is more determined by the number of organ failure (SOFA score) then by the deterioration of the liver function. In a critical situation, hyperlactatemia is mainly associated with respiratory and cardiovascular dysfunction, both of which may lead to systemic tissue hypoxia. In cirrhotic patients admitted to the ICU, hyperlactatemia may reflect both an increased production (overproduction due to systemic tissue hypoxia associated with multiorgan failure) and a decreased hepatic clearance (due to hepatic dysfunction). In our cohort, we did not evaluate this marker because it is not included in the different prognostics scores studied in our paper (SAPS II, SOFA, MELD…). Cholongitas et al. suggest that arterial lactate may be a prognostic marker in patients with cirrhosis admitted to ICU. Although, there is a lack of information in the data provided by Cholongitas et al., it may be interesting to know whether a significant correlation between arterial lactate and SOFA score, the presence of sepsis or the number of organ dysfunction exists. Even though these associations dot not necessarily imply causality, they do suggest that multiple organ failure could be involved in the development of hyperlactatemia. With the SOFA score at admission, the severity of organ dysfunction assessment and their change over time, the liver function, the primary ICU diagnosis (sepsis or systemic inflammation), and a possible candidacy for liver transplantation, the arterial lactate may be an additional tool for the decision-making process in the management of cirrhotic patients admitted to ICU. But, to identify, in emergency at ICU admission, patients who might benefit from an ICU transfer and from an aggressive treatment is still complex and challenging. We agree with Cholongitas et al. that all cirrhotic patients admitted to ICU require re-assessment in the days following the admission. For some cirrhotic patients, the ICU treatment is futile and generates a significant cost. Consequently, as we concluded in our study, criteria consisting of a combination of factors such SOFA and MELD scores, together with the development of sepsis and/or the need for organ support, might result in an improved predictive power over each component alone and will provide guidance to the optimal management of cirrhotic patients admitted to the ICU. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.