Patients with cirrhosis admitted to an Intensive Care Unit
Authors: Evangelos Cholongitas, Banwari Agarwal, Nikolaos Antoniadis, Andrew K. Burroughs
Journal: Journal of Hepatology (2012)

Prospective 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 Reply to: “Patients with cirrhosis admitted to an Intensive Care Unit”Journal of HepatologyVol. 57Issue 1PreviewWe 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. Full-Text PDF Open Access We read with great interest the study by Levesque et al. [[1]Levesque E. Hoti E. Azoulay D. Ichaï P. Habouchi H. Castaing D. et al.Prospective evaluation of the prognostic scores for cirrhotic patients admitted to an intensive care unit.J Hepatol. 2012; 56: 95-102Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar], 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]Cholongitas E. Senzolo M. Patch D. Shaw S. Hui C. Burroughs A.K. Review article: scoring systems for assessing prognosis in critically ill adult cirrhotics.Aliment Pharmacol Ther. 2006; 24: 453-464Crossref PubMed Scopus (126) Google Scholar] 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]Cholongitas E. Senzolo M. Patch D. Kwong K. Nikolopoulou V. Leandro G. 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; 23: 883-893Crossref PubMed Scopus (199) Google Scholar], which showed that the SOFA score had better discriminative accuracy for mortality, compared to the MELD score. To add to their evaluation, we report our experience in 412 patients with cirrhosis who were consecutively admitted to ICU. At admission, several variables, including demographic and clinical data, as well as laboratory parameters had been prospectively collected for each patient. During the ICU stay, gastrointestinal bleeding episodes, development of aspiration pneumonia and additional use of inotropes, mechanical ventilation or haemofiltration were also recorded. Univariate comparisons and then multivariate analysis of variables at baseline were performed to identify independent factors associated with mortality. Liver-specific prognostic models [CTP, standard MELD, MELD-sodium (MELD-Na, iMELD, and MESO) scores], as well as general ICU models (APACHE II and SOFA scores) were evaluated on ICU admission. In addition, we evaluated for the first time the performance of the re-weighted MELD. The discriminative ability of the prognostic models to predict the outcome of patients was evaluated by using AUC, while sensitivity, specificity, positive (PPV), and negative (NPV) predictive values were calculated. The overall mortality in ICU or in hospital was 61.2% and 187 (45.4%) patients died due to multiple organ failure. Arterial lactate was independently associated with mortality (OR: 1.23, p = 0.001). The cirrhotics who died, compared to those who survived, had significantly higher median values of CTP (12 vs. 10), APACHE II (21 vs. 16), MELD (28 vs. 18) MELD-sodium (MELD-Na: 32 vs. 23, iMELD: 47 vs. 37, and MESO: 2.1 vs. 1.4) scores, re-weighted MELD (5.4 vs. 4.1), and SOFA (12 vs. 9) scores (p <0.001) at admission. Table 1 shows the discriminative ability, sensitivity, specificity, PPV, NPV of prognostic scores at the best cut-off point in our cohort. Similar to the study by Levesque et al. [[1]Levesque E. Hoti E. Azoulay D. Ichaï P. Habouchi H. Castaing D. et al.Prospective evaluation of the prognostic scores for cirrhotic patients admitted to an intensive care unit.J Hepatol. 2012; 56: 95-102Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar], we found that the SOFA score had the best discriminative accuracy for outcome (AUC = 0.85), followed by the standard MELD score (AUC = 0.80), but their difference was not significant (p = 0.27). In addition, we found no difference between the standard MELD and the different models incorporating serum sodium (MELD-Na, iMELD, and MESO) (AUC: 0.75, 0.76, and 0.78, respectively, p >0.05 for all comparisons), while the re-weighted MELD had also similar performance (AUC: 0.79, p >0.05). SOFA score had the highest specificity, but, in contrast to Levesque et al. [[1]Levesque E. Hoti E. Azoulay D. Ichaï P. Habouchi H. Castaing D. et al.Prospective evaluation of the prognostic scores for cirrhotic patients admitted to an intensive care unit.J Hepatol. 2012; 56: 95-102Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar], the NPV was relatively low in all prognostic scores.Table 1Prediction of mortality in 412 cirrhotics admitted to intensive care unit.PPV, positive predictive value; NPV, negative predictive value. Open table in a new tab PPV, positive predictive value; NPV, negative predictive value. Thus, deterioration of liver function is not the main determinant of outcome in cirrhotics admitted to ICU [[2]Cholongitas E. Senzolo M. Patch D. Shaw S. Hui C. Burroughs A.K. Review article: scoring systems for assessing prognosis in critically ill adult cirrhotics.Aliment Pharmacol Ther. 2006; 24: 453-464Crossref PubMed Scopus (126) Google Scholar], which is important, as improvement in multi-organ support, and not just liver support, such as MARS, is needed to improve outcome. In fact, the severity of organ dysfunction changes over time, either due to progressive illness or therapeutic intervention, and therefore, a prognostic system measured at subsequent time points may be more accurate, compared to baseline. Indeed, we showed this for the first time, in that the SOFA score performed better at 48 h, compared to that calculated at admission [[4]Cholongitas E. Betrosian A. Senzolo M. Shaw S. Patch D. Manousou P. et al.Prognostic models in cirrhotics admitted to intensive care units better predict outcome when assessed at 48 h after admission.J Gastroenterol Hepatol. 2008; 23: 1223-1227Crossref PubMed Scopus (65) Google Scholar]. This requires further validation, but does confirm that the SOFA score in general is a valid clinical tool for clinical decision-making. Finally, Levesque et al. [[1]Levesque E. Hoti E. Azoulay D. Ichaï P. Habouchi H. Castaing D. et al.Prospective evaluation of the prognostic scores for cirrhotic patients admitted to an intensive care unit.J Hepatol. 2012; 56: 95-102Abstract Full Text Full Text PDF PubMed Scopus (143) Google Scholar] did not evaluate arterial lactate, but in our cohort, it was an independent factor related to mortality. We believe that lactate should be incorporated as a tool for evaluation of treatment response. Arterial lactate reflects multiple organ dysfunction and serial measurements of lactate (at admission and after 48 h) have been associated with the adverse outcomes in patients with acute complications of cirrhosis [[4]Cholongitas E. Betrosian A. Senzolo M. Shaw S. Patch D. Manousou P. et al.Prognostic models in cirrhotics admitted to intensive care units better predict outcome when assessed at 48 h after admission.J Gastroenterol Hepatol. 2008; 23: 1223-1227Crossref PubMed Scopus (65) Google Scholar]. The authors declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.