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1
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McPhail MJW. Is it time to open the doors of the intensive care unit further for patients with alcohol-related liver disease? Anaesthesia 2025. [PMID: 40414689 DOI: 10.1111/anae.16649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/02/2025] [Indexed: 05/27/2025]
Affiliation(s)
- Mark J W McPhail
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College London, London, UK
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2
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Hortelã FR, Kruger RS, de Oliveira VF, Carraro H, Muzzillo DA, Kowalski SC. Hepatorenal Syndrome: direct treatment costs and characteristics of patients admitted to intensive care. EINSTEIN-SAO PAULO 2025; 23:eGS0390. [PMID: 40197881 PMCID: PMC12014156 DOI: 10.31744/einstein_journal/2025gs0390] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/21/2022] [Accepted: 10/04/2024] [Indexed: 04/10/2025] Open
Abstract
BACKGROUND Hepatorenal Syndrome is a potentially reversible syndrome of endstage cirrhosis. It is a severe complication of cirrhosis that involves a high mortality rate and a significant economic impact on the healthcare system. This study shows the costs of the resources used for disease management and complications to be Int$14,189. Quantifying this figure contributes to an understanding of the economic impact of Hepatorenal Syndrome on patient survival. OBJECTIVE The purpose of this study was to describe the direct medical costs incurred in Brazil for the treatment of Hepatorenal Syndrome in intensive care and intermediate therapy care units, and to investigate the impact of this syndrome on patient survival. METHODS This longitudinal observational retrospective study included patients with Hepatorenal Syndrome admitted to the intensive and intermediate therapy care units of a public tertiary hospital. The cost generated by each patient was the sum of the direct costs and overheads. RESULTS Forty-four patients with 49 episodes of suspected Hepatorenal Syndrome were analyzed, 73% male, with a mean age of 55 years (SD= 11). Diagnosis was presumed in 21 episodes (43%), because not all of the Ascites International Club's criteria were met. Alcoholic cirrhosis was the main etiology (43%); 59% of the patients were Child-Pugh Class C at admission, with a mean (SD) model for end-stage liver disease score of 24.6 (8). Seventy-seven percent of the patients died, 32% from multiple organ failure, 29% of septic shock and 27% of hypovolemic shock. The median (IQR) of the total treatment cost for each patient was Int$14,819 (8,732-23,854). The median (IQR) length of intensive care unit stay in intensive care was 11 days (7-19). Patients with a presumed diagnosis did not have a higher hospitalization cost (p=0.249) than those with true Hepatorenal Syndrome. CONCLUSION The treatment of Hepatorenal Syndrome represents a significant cost, and new resource allocation in strategic areas, such as the treatment and monitoring of patients with cirrhosis, is necessary to improve their outcomes. BACKGROUND ■ The treatment of Hepatorenal Syndrome places a huge economic burden on healthcare systems. BACKGROUND ■ Cost analysis studies of Hepatorenal Syndrome management can help to rationally allocate resources in healthcare. BACKGROUND ■ Timely diagnosis and management of Hepatorenal Syndrome may reduce mortality, resource utilization and costs.
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Affiliation(s)
- Franciele Robes Hortelã
- Postgraduate Program in Internal Medicine and Health SciencesComplexo Hospital de ClínicasUniversidade Federal do ParanáCuritibaPRBrazil Postgraduate Program in Internal Medicine and Health Sciences, Complexo Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Rodrigo Sfredo Kruger
- Semi-Intensive Therapy CenterComplexo Hospital de ClínicasUniversidade Federal do ParanáCuritibaPRBrazil Semi-Intensive Therapy Center, Complexo Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Valéria Filomena de Oliveira
- Cost Accounting UnitComplexo Hospital de ClínicasUniversidade Federal do ParanáCuritibaPRBrazil Cost Accounting Unit, Complexo Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Hipolito Carraro
- Intensive Care UnitComplexo Hospital de ClínicasUniversidade Federal do ParanáCuritibaPRBrazil Intensive Care Unit, Complexo Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Dominique Araújo Muzzillo
- Department of Internal MedicineComplexo Hospital de ClínicasUniversidade Federal do ParanáCuritibaPRBrazil Department of Internal Medicine, Complexo Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
| | - Sérgio Candido Kowalski
- Department of Internal MedicineComplexo Hospital de ClínicasUniversidade Federal do ParanáCuritibaPRBrazil Department of Internal Medicine, Complexo Hospital de Clínicas, Universidade Federal do Paraná, Curitiba, PR, Brazil.
- Department of Health Research Methods, Evidence, and ImpactMcMaster UniversityHamiltonCanada Department of Health Research Methods, Evidence, and Impact, McMaster University, Hamilton, Canada.
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3
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Schulz MS, Angeli P, Trebicka J. Acute and non-acute decompensation of liver cirrhosis (47/130). Liver Int 2025; 45:e15861. [PMID: 38426268 PMCID: PMC11815624 DOI: 10.1111/liv.15861] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2023] [Revised: 12/18/2023] [Accepted: 01/19/2024] [Indexed: 03/02/2024]
Abstract
In the traditional view, the occurrence of cirrhosis-related complications, such as hepatic encephalopathy, formation of ascites or variceal haemorrhage, marks the transition to the decompensated stage of cirrhosis. Although the dichotomous stratification into a compensated and decompensated state reflects a prognostic water-shed moment and remains to hold its prognostic validity, it represents an oversimplification of clinical realities. A broadening understanding of pathophysiological mechanisms underpinning decompensation have led to the identification of distinct prognostic subgroups, associated with different clinical courses following decompensation. Data provided by the PREDICT study uncovered three distinct sub-phenotypes of acute decompensation (AD). Moreover, acute-on-chronic liver failure (ACLF) has been established as a distinct clinical entity for many years, which is associated with a high short-term mortality. Recently, non-acute decompensation (NAD) has been proposed as a distinct pathway of decompensation, complementing current concepts of the spectrum of decompensation. In contrast to AD, NAD is characterized by a slow and progressive development of complications, which are often presented at first decompensation and/or in patients in an earlier stage of chronic liver disease. Successful treatment of AD or NAD may lead to a clinical stabilization or even the concept of recompensation. This review aims to provide an overview on current concepts of decompensation and to delineate recent advances in our clinical and pathophysiological understanding.
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Affiliation(s)
- Martin S. Schulz
- Department of Internal Medicine BUniversity of MünsterMünsterGermany
| | - Paolo Angeli
- European Foundation for Study of Chronic Liver FailureBarcelonaSpain
| | - Jonel Trebicka
- Department of Internal Medicine BUniversity of MünsterMünsterGermany
- European Foundation for Study of Chronic Liver FailureBarcelonaSpain
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4
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Juanola A, Tiwari N, Solé C, Adebayo D, Wong F, Ginès P. Organ dysfunction and failure in liver disease. Liver Int 2025; 45:e15622. [PMID: 37222263 DOI: 10.1111/liv.15622] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 05/15/2023] [Indexed: 05/25/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a complex syndrome defined by the existence of different organ failures (OFs) in patients with chronic liver disease, mainly cirrhosis. Several definitions have been proposed to define the syndrome, varying in the grade of the subjacent liver disease, the type of precipitants and the organs considered in the definition. Liver, coagulation, brain, kidney, circulatory and pulmonary are the six types of OFs proposed in the different classifications, with different prevalence worldwide. Irrespective of the definition used, patients who develop ACLF present a hyperactive immune system, profound haemodynamic disturbances and several metabolic alterations that finally lead to organ dysfunction. These disturbances are triggered by different factors such as bacterial infections, alcoholic hepatitis, gastrointestinal bleeding or hepatitis B virus flare, among others. Because patients with ACLF present high short-term mortality, a prompt recognition is needed to start treatment of the trigger event and specific organ support. Liver transplantation is also feasible in carefully selected patients and should be evaluated.
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Affiliation(s)
- Adrià Juanola
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
| | - Neha Tiwari
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Cristina Solé
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
- Department of Gastroenterology and Hepatology, Parc Tauli Hospital Universitari, Institut d'Investigació i Innovació Parc Taulí (I3PT-CERCA), Universitat Autònoma de Barcelona, Sabadell, Spain
| | - Danielle Adebayo
- Department of Gastroenterology, Royal Berkshire NHS Foundation Trust, Reading, UK
| | - Florence Wong
- Division of Gastroenterology and Hepatology, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Pere Ginès
- Liver Unit, Hospital Clínic de Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
- Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Spain
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5
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Tariparast PA, Roedl K, Horvatits T, Drolz A, Kluge S, Fuhrmann V. Impact of acute respiratory distress syndrome on outcome in critically ill patients with liver cirrhosis. Sci Rep 2025; 15:4301. [PMID: 39905232 PMCID: PMC11794433 DOI: 10.1038/s41598-025-88606-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2024] [Accepted: 01/29/2025] [Indexed: 02/06/2025] Open
Abstract
We investigated the occurrence and outcome of respiratory failure and ARDS in critically ill patients with liver cirrhosis. This is a retrospective analysis of patients with liver cirrhosis at an ICU during an 8-Year period. An assessment of acute on chronic liver failure as well as the presence and grade of ARDS within the first 72 h of admission to the ICU was performed. A total of 735 patients during the study period. Median age was 58 (50-69) years and 61% (n = 447) were male. 57% (n = 421) of the patients received mechanical ventilation (MV). Liver specific as well as ICU scores on admission were significantly higher in patients with MV. Necessity of vasopressor support (86%vs.25%, p < 0.001) and RRT (50%vs.11%, p < 0.001) was more frequent in patients with MV. The incidence of ARDS within the first 72 h of admission was 8% (n = 61). We observed a 28-day mortality or liver transplantation rate of 54% (n = 196) and 66% (n = 66%) in patients with MV and ARDS, respectively. After 90-days 63% (n = 226) with MV and 70% (n = 43) with ARDS were dead or received liver transplantation. ARDS is a prognostic factor for mortality in patients with liver cirrhosis admitted to the ICU. One out of ten critically ill cirrhotic patients develop ARDS within 72 h after admission. Although mortality rates are high initially critical care therapy should not be withheld and must be reevaluated regularly.
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Affiliation(s)
- Pischtaz Adel Tariparast
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany.
| | - Thomas Horvatits
- Department of Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Andreas Drolz
- Department of Medicine I, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Martinistr. 52, 20246, Hamburg, Germany
- Department of Medicine and Gastroenterology, Heilig Geist-Hospital, Cologne, Germany
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6
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Cerutti E, D'Arcangelo F, Becchetti C, Cilla M, Cossiga V, Guarino M, Invernizzi F, Lapenna L, Lavezzo B, Marra F, Merli M, Morelli MC, Toniutto P, Burra P, Zanetto A. Sex disparities in acute-on-chronic liver failure: From admission to the intensive care unit to liver transplantation. Dig Liver Dis 2025; 57:355-361. [PMID: 39164168 DOI: 10.1016/j.dld.2024.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/14/2024] [Revised: 07/01/2024] [Accepted: 08/04/2024] [Indexed: 08/22/2024]
Abstract
Acute-on-chronic liver failure (ACLF) is a severe clinical syndrome characterized by acute liver decompensation in patients with chronic liver disease, marked by systemic inflammation and systemic organ failure. In this review, we discussed sex-related disparities in the incidence, prognosis, and access to liver transplantation (LT) for patients with ACLF, particularly during Intensive Care Unit (ICU) management. Some studies have suggested that ACLF is more prevalent among male patients admitted to the ICU, and they have higher mortality rates than females. Available prognostic scores, such as CLIF-C or TAM-score, lack sex-specific adjustments. Sarcopenia seems to enhance the accuracy of these scores though this is observed only in male individuals. LT is the only effective treatment for patients with ACLF grade 2-3 who do not respond to medical therapies. Sex-related disparities occur in both access to LT and post-transplant outcomes, although the influence of sex on the prevalence, clinical course, and listing for LT in ACLF remains largely undetermined. A sex-orientated analysis of ICU outcomes in ACLF would facilitate the development of sex-orientated management strategies, thereby improving patients' outcomes.
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Affiliation(s)
- Elisabetta Cerutti
- Department of Anesthesia, Transplant and Surgical Intensive Care, Azienda Ospedaliero Universitaria delle Marche, Ancona, Italy
| | - Francesca D'Arcangelo
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, Padua, Italy
| | - Chiara Becchetti
- Hepatology and Gastroenterology, ASST Grande Ospedale Metropolitano Niguarda, Milan, Italy
| | - Marta Cilla
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Valentina Cossiga
- Diseases of the Liver and Biliary System Unit, Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Maria Guarino
- Diseases of the Liver and Biliary System Unit, Department of Clinical Medicine and Surgery, University of Naples "Federico II", 80131 Naples, Italy
| | - Federica Invernizzi
- Center for Liver Disease, Division of Internal Medicine and Hepatology, IRCCS Ospedale San Raffaele, 20132 Milan, Italy
| | - Lucia Lapenna
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Bruna Lavezzo
- Emergency Department, Anesthesia and Intensive Care Unit, SS Annunziata Hospital, Savigliano ASL Cuneo, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Maria Cristina Morelli
- Internal Medicine Unit for the Treatment of Severe Organ Failure, IRCCS Azienda Ospedaliero-Universitaria di Bologna, 40138 Bologna, Italy
| | - Pierluigi Toniutto
- Hepatology and Liver Transplantation Unit, Academic Hospital, University of Udine, Udine, Italy
| | - Patrizia Burra
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, Padua, Italy.
| | - Alberto Zanetto
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy; Gastroenterology and Multivisceral Transplant Unit, Padua University Hospital, Padua, Italy
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7
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Pollmanns MR, Kister B, Abu Jhaisha S, Adams JK, Kabak E, Brozat JF, Schneider CV, Hohlstein P, Bruns T, Küpfer L, Trautwein C, Koch A, Wirtz TH. The Aachen ACLF ICU score predicts ICU mortality in critically ill patients with acute-on-chronic liver failure. Sci Rep 2024; 14:30497. [PMID: 39681633 DOI: 10.1038/s41598-024-82178-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/18/2024] [Accepted: 12/03/2024] [Indexed: 12/18/2024] Open
Abstract
Acute-on-chronic liver failure (ACLF) defines a heterogeneous syndrome involving acute decompensation in patients with pre-existing liver disease accompanied by (multi-)organ failure. This study aimed to develop a simple, reliable machine learning (ML) model to predict mortality in ACLF patients receiving intensive care unit (ICU) treatment. Data from 206 patients admitted to the ICU at RWTH Aachen University Hospital between 2015 and 2021 were retrospectively analyzed with ICU mortality as the primary outcome. An ICU mortality prediction model was developed by logistic regression and validated by 5-fold cross validation. Performance metrics were assessed to evaluate the model's accuracy and compare to existing mortality scores. ICU mortality was 60%. The chronic-liver-failure-consortium ACLF score (CLIF-C ACLFs) was the best predictor of ICU mortality. ML generated seven models using five to thirteen features. The best-performing model included CLIF-C ACLFs, number of organ failures, Horovitz quotient (FiO2/PaO2), FiO2 and lactate. The newly developed Aachen ACLF ICU (ACICU) score demonstrated exceptional predictive accuracy for ICU mortality (AUROC 0.96), underscoring its potential for mortality and futility assessment in critically ill ACLF patients complementing existing prognostic tools. The ACICU score www.acicu-score.com is an easy-to-use tool for predicting ICU mortality in patients with ACLF offering high predictive performance.
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Affiliation(s)
- Maike R Pollmanns
- Medical Department III, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Bastian Kister
- Institute for Systems Medicine with Focus on Organ Interaction, RWTH Aachen University, Aachen, Germany
| | - Samira Abu Jhaisha
- Medical Department III, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jule K Adams
- Medical Department III, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Elena Kabak
- Medical Department III, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Jonathan F Brozat
- Medical Department III, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
- Department of Hepatology and Gastroenterology, Charité-Universitätsmedizin Berlin, Campus Virchow-Klinikum (CVK) and Campus Charité Mitte (CCM), Berlin, Germany
| | - Carolin V Schneider
- Medical Department III, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Philipp Hohlstein
- Medical Department III, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Tony Bruns
- Medical Department III, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Lars Küpfer
- Institute for Systems Medicine with Focus on Organ Interaction, RWTH Aachen University, Aachen, Germany
| | - Christian Trautwein
- Medical Department III, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
- Leibniz Research Centre for Working Environment and Human Factors at the TU Dortmund (IfADo), Dortmund, Germany
| | - Alexander Koch
- Medical Department III, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany
| | - Theresa H Wirtz
- Medical Department III, RWTH Aachen University Hospital, Pauwelsstraße 30, 52074, Aachen, Germany.
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8
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Pompili E, Iannone G, Carrello D, Zaccherini G, Baldassarre M, Caraceni P. Managing Multiorgan Failure in Acute on Chronic Liver Failure. Semin Liver Dis 2024; 44:492-509. [PMID: 39442531 DOI: 10.1055/a-2448-0664] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/25/2024]
Abstract
Acute-on-chronic liver failure (ACLF) is defined as a clinical syndrome that develops in patients with chronic liver disease characterized by the presence of organ failure and high short-term mortality, although there is still no worldwide consensus on diagnostic criteria. Management of ACLF is mainly based on treatment of "precipitating factors" (the most common are infections, alcohol-associated hepatitis, hepatitis B flare, and bleeding) and support of organ failure, which often requires admission to the intensive care unit. Liver transplantation should be considered in patients with ACLF grades 2 to 3 as a potentially life-saving treatment. When a transplant is not indicated, palliative care should be considered after 3 to 7 days of full organ support in patients with at least four organ failures or a CLIF-C ACLF score of >70. This review summarizes the current knowledge on the management of organ failure in patients with ACLF, focusing on recent advances.
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Affiliation(s)
- Enrico Pompili
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giulia Iannone
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Daniele Carrello
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Giacomo Zaccherini
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Maurizio Baldassarre
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Paolo Caraceni
- Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
- Unit of Semeiotics, Liver and Alcohol-Related Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
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9
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Kaya E, Nekarda P, Traut I, Aurich P, Canbay A, Katsounas A. [When should a liver disease patient be admitted to the intensive care unit?]. Med Klin Intensivmed Notfmed 2024; 119:470-477. [PMID: 39017943 DOI: 10.1007/s00063-024-01160-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2024] [Revised: 05/27/2024] [Accepted: 06/04/2024] [Indexed: 07/18/2024]
Abstract
Liver diseases are a significant global cause of morbidity and mortality. Liver cirrhosis can result in severe complications such as bleeding, hepatic encephalopathy (HE), and infections. Implementing a clear strategy for intensive care unit (ICU) admission management improves patient outcomes. Hemodynamically significant esophageal/gastric variceal bleeding (E/GVB) and grade 4 HE, when accompanied by the need for renal replacement therapy (RRT), are definitive indications for ICU admission. E/GVB, spontaneous bacterial peritonitis (SBP), and infections with multidrug-resistant organisms (MDRO) require close and stringent critical assessment. Patients with severe hepatorenal syndrome (HRS) or respiratory failure have increased baseline mortality and most likely benefit from early ICU treatment. Rapid identification of sepsis in patients with liver cirrhosis is a crucial criterion for ICU admission. Prioritizing cases based on mortality risk and clinical urgency enables efficient resource utilization and optimizes patient management. In addition, "Liver Units" provide an intermediate care (IMC) level for patients with liver diseases who require close monitoring but do not need immediate intensive care.
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Affiliation(s)
- Eda Kaya
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - Patrick Nekarda
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - Isabella Traut
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - Philipp Aurich
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - Ali Canbay
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland
| | - Antonios Katsounas
- Medizinische Klinik, Universitätsklinikum Knappschaftskrankenhaus Bochum GmbH, Ruhr-Universität Bochum, In der Schornau 23-25, 44892, Bochum, Deutschland.
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10
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de Haan J, Termorshuizen F, de Keizer N, Gommers D, Hoed CD. One-year transplant-free survival following hospital discharge after ICU admission for ACLF in the Netherlands. J Hepatol 2024; 81:238-247. [PMID: 38479613 DOI: 10.1016/j.jhep.2024.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2023] [Revised: 03/05/2024] [Accepted: 03/06/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND & AIMS Patients with acute decompensation of cirrhosis or acute-on-chronic liver failure (ACLF) often require intensive care unit (ICU) admission for organ support. Existing research, mostly from specialized liver transplant centers, largely addresses short-term outcomes. Our aim was to evaluate in-hospital mortality and 1-year transplant-free survival after hospital discharge in the Netherlands. METHODS We conducted a nationwide observational cohort study, including patients with a history of cirrhosis or first complications of cirrhotic portal hypertension admitted to ICUs in the Netherlands between 2012 and 2020. The influence of ACLF grade at ICU admission on 1-year transplant-free survival after hospital discharge among hospital survivors was evaluated using unadjusted Kaplan-Meier survival curves and an adjusted Cox proportional hazard model. RESULTS Out of the 3,035 patients, 1,819 (59.9%) had ACLF-3. 1,420 patients (46.8%) survived hospitalization after ICU admission. The overall probability of 1-year transplant-free survival after hospital discharge was 0.61 (95% CI 0.59-0.64). This rate varied with ACLF grade at ICU admission, being highest in patients without ACLF (0.71; 95% CI 0.66-0.76) and lowest in those with ACLF-3 (0.53 [95% CI 0.49-0.58]) (log-rank p <0.0001). However, after adjusting for age, malignancy status and MELD score, ACLF grade at ICU admission was not associated with an increased risk of liver transplantation or death within 1 year after hospital discharge. CONCLUSION In this nationwide cohort study, ACLF grade at ICU admission did not independently affect 1-year transplant-free survival after hospital discharge. Instead, age, presence of malignancy and the severity of liver disease played a more prominent role in influencing transplant-free survival after hospital discharge. IMPACT AND IMPLICATIONS Patients with acute-on-chronic liver failure often require intensive care unit (ICU) admission for organ support. In these patients, short-term mortality is high, but long-term outcomes of survivors remain unknown. Using a large nationwide cohort of ICU patients, we discovered that the severity of acute-on-chronic liver failure at ICU admission does not influence 1-year transplant-free survival after hospital discharge. Instead, age, malignancy status and overall severity of liver disease are more critical factors in determining their long-term survival.
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Affiliation(s)
- Jubi de Haan
- Department of Adult Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands.
| | - Fabian Termorshuizen
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, the Netherlands; Department of Medical Informatics, Amsterdam Public Health Institute, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Nicolette de Keizer
- National Intensive Care Evaluation (NICE) Foundation, Amsterdam, the Netherlands; Department of Medical Informatics, Amsterdam Public Health Institute, Amsterdam UMC, University of Amsterdam, the Netherlands
| | - Diederik Gommers
- Department of Adult Intensive Care, Erasmus University Medical Center, Rotterdam, the Netherlands
| | - Caroline den Hoed
- Department of Gastroenterology and Hepatology, Erasmus MC Transplant Institute, Erasmus University Medical Center, Rotterdam, the Netherlands
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11
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Kosuta I, Premkumar M, Reddy KR. Review article: Evaluation and care of the critically ill patient with cirrhosis. Aliment Pharmacol Ther 2024; 59:1489-1509. [PMID: 38693712 DOI: 10.1111/apt.18016] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 03/21/2024] [Accepted: 04/12/2024] [Indexed: 05/03/2024]
Abstract
BACKGROUND The increase in prevalence of liver disease globally will lead to a substantial incremental burden on intensive care requirements. While liver transplantation offers a potential life-saving intervention, not all patients are eligible due to limitations such as organ availability, resource constraints, ongoing sepsis or multiple organ failures. Consequently, the focus of critical care of patients with advanced and decompensated cirrhosis turns to liver-centric intensive care protocols, to mitigate the high mortality in such patients. AIM Provide an updated and comprehensive understanding of cirrhosis management in critical care, and which includes emergency care, secondary organ failure management (mechanical ventilation, renal replacement therapy, haemodynamic support and intensive care nutrition), use of innovative liver support systems, infection control, liver transplantation and palliative and end-of life care. METHODS We conducted a structured bibliographic search on PubMed, sourcing articles published up to 31 March 2024, to cover topics addressed. We considered data from observational studies, recommendations of society guidelines, systematic reviews, and meta-analyses, randomised controlled trials, and incorporated our clinical expertise in liver critical care. RESULTS Critical care management of the patient with cirrhosis has evolved over time while mortality remains high despite aggressive management with liver transplantation serving as a crucial but not universally available resource. CONCLUSIONS Implementation of organ support therapies, intensive care protocols, nutrition, palliative care and end-of-life discussions and decisions are an integral part of critical care of the patient with cirrhosis. A multi-disciplinary approach towards critical care management is likely to yield better outcomes.
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Affiliation(s)
- Iva Kosuta
- Department of Intensive Care Medicine, University Hospital Centre Zagreb, Zagreb, Croatia
| | - Madhumita Premkumar
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
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12
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Tang XW, Ren WS, Huang S, Zou K, Xu H, Shi XM, Zhang W, Shi L, Lü MH. Development and validation of a nomogram for predicting in-hospital mortality of intensive care unit patients with liver cirrhosis. World J Hepatol 2024; 16:625-639. [PMID: 38689750 PMCID: PMC11056901 DOI: 10.4254/wjh.v16.i4.625] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2023] [Revised: 02/23/2024] [Accepted: 03/18/2024] [Indexed: 04/24/2024] Open
Abstract
BACKGROUND Liver cirrhosis patients admitted to intensive care unit (ICU) have a high mortality rate. AIM To establish and validate a nomogram for predicting in-hospital mortality of ICU patients with liver cirrhosis. METHODS We extracted demographic, etiological, vital sign, laboratory test, comorbidity, complication, treatment, and severity score data of liver cirrhosis patients from the Medical Information Mart for Intensive Care IV (MIMIC-IV) and electronic ICU (eICU) collaborative research database (eICU-CRD). Predictor selection and model building were based on the MIMIC-IV dataset. The variables selected through least absolute shrinkage and selection operator analysis were further screened through multivariate regression analysis to obtain final predictors. The final predictors were included in the multivariate logistic regression model, which was used to construct a nomogram. Finally, we conducted external validation using the eICU-CRD. The area under the receiver operating characteristic curve (AUC), decision curve, and calibration curve were used to assess the efficacy of the models. RESULTS Risk factors, including the mean respiratory rate, mean systolic blood pressure, mean heart rate, white blood cells, international normalized ratio, total bilirubin, age, invasive ventilation, vasopressor use, maximum stage of acute kidney injury, and sequential organ failure assessment score, were included in the multivariate logistic regression. The model achieved AUCs of 0.864 and 0.808 in the MIMIC-IV and eICU-CRD databases, respectively. The calibration curve also confirmed the predictive ability of the model, while the decision curve confirmed its clinical value. CONCLUSION The nomogram has high accuracy in predicting in-hospital mortality. Improving the included predictors may help improve the prognosis of patients.
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Affiliation(s)
- Xiao-Wei Tang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
- Nuclear Medicine and Molecular Imaging Key Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Wen-Sen Ren
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
- Nuclear Medicine and Molecular Imaging Key Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Shu Huang
- Department of Gastroenterology, Lianshui People' Hospital of Kangda College Affiliated to Nanjing Medical University, Huaian 223499, Jiangsu Province, China
| | - Kang Zou
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
- Nuclear Medicine and Molecular Imaging Key Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Huan Xu
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
- Nuclear Medicine and Molecular Imaging Key Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Xiao-Min Shi
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
- Nuclear Medicine and Molecular Imaging Key Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Wei Zhang
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
- Nuclear Medicine and Molecular Imaging Key Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Lei Shi
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
- Nuclear Medicine and Molecular Imaging Key Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
| | - Mu-Han Lü
- Department of Gastroenterology, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China
- Nuclear Medicine and Molecular Imaging Key Laboratory, The Affiliated Hospital of Southwest Medical University, Luzhou 646099, Sichuan Province, China.
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Xu M, Chen Y, Artru F. Acute decompensation of cirrhosis versus acute-on-chronic liver failure: What are the clinical implications? United European Gastroenterol J 2024; 12:194-202. [PMID: 38376886 PMCID: PMC10954432 DOI: 10.1002/ueg2.12538] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 12/20/2023] [Indexed: 02/21/2024] Open
Abstract
It is essential to identify the subgroup of patients who experience poorer outcomes in order to adapt clinical management effectively. In the context of liver disease, the earlier the identification occurs, the greater the range of therapeutic options that can be offered to patients. In the past, patients with acute decompensation (AD) of chronic liver disease were treated as a homogeneous group, with emphasis on identifying those at the highest risk of death. In the last 15 years, a differentiation has emerged between acute-on-chronic liver failure syndrome (ACLF) and AD, primarily due to indications that the latter is linked to a less favorable short-term prognosis. Nevertheless, the definition of ACLF varies among the different knowledge societies, making it challenging to assess its true impact compared with AD. Therefore, the purpose of this review is to provide a detailed analysis emphasizing the critical importance of identifying ACLF in the field of advanced liver disease. We will discuss the differences between Eastern and Western approaches, particularly in relation to the occurrence of liver failure and disease onset. Common characteristics, such as the dynamic nature of the disease course, will be highlighted. Finally, we will focus on two key clinical implications arising from these considerations: the prevention of ACLF before its onset and the clinical management strategies once it develops, including liver transplantation and withdrawal of care.
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Affiliation(s)
- Manman Xu
- Fourth Department of Liver Disease (Difficult & Complicated Liver Diseases and Artificial Liver Center)Beijing You'an Hospital Affiliated to CapitalMedical UniversityBeijingChina
- Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment ResearchBeijingChina
| | - Yu Chen
- Fourth Department of Liver Disease (Difficult & Complicated Liver Diseases and Artificial Liver Center)Beijing You'an Hospital Affiliated to CapitalMedical UniversityBeijingChina
- Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment ResearchBeijingChina
| | - Florent Artru
- Institute of Liver StudiesKing's College HospitalLondonUK
- Liver Disease DepartmentRennes University HospitalRennesFrance
- Rennes University and Inserm NuMeCan UMR 1317RennesFrance
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14
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Li J, Yang D, Ge S, Liu L, Huo Y, Hu Z. Identifying hub genes of sepsis-associated and hepatic encephalopathies based on bioinformatic analysis-focus on the two common encephalopathies of septic cirrhotic patients in ICU. BMC Med Genomics 2024; 17:19. [PMID: 38212812 PMCID: PMC10785360 DOI: 10.1186/s12920-023-01774-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2023] [Accepted: 12/12/2023] [Indexed: 01/13/2024] Open
Abstract
BACKGROUND In the ICU ward, septic cirrhotic patients are susceptible to suffering from sepsis-associated encephalopathy and/or hepatic encephalopathy, which are two common neurological complications in such patients. However, the mutual pathogenesis between sepsis-associated and hepatic encephalopathies remains unclear. We aimed to identify the mutual hub genes, explore effective diagnostic biomarkers and therapeutic targets for the two common encephalopathies and provide novel, promising insights into the clinical management of such septic cirrhotic patients. METHODS The precious human post-mortem cerebral tissues were deprived of the GSE135838, GSE57193, and GSE41919 datasets, downloaded from the Gene Expression Omnibus database. Furthermore, we identified differentially expressed genes and screened hub genes with weighted gene co-expression network analysis. The hub genes were then subjected to Gene Ontology and Kyoto Encyclopedia of Genes and Genomes pathway functional enrichment analyses, and protein-protein interaction networks were constructed. Receiver operating characteristic curves and correlation analyses were set up for the hub genes. Finally, we explored principal and common signaling pathways by using Gene Set Enrichment Analysis and the association between the hub genes and immune cell subtype distribution by using CIBERSORT algorithm. RESULTS We identified seven hub genes-GPR4, SOCS3, BAG3, ZFP36, CDKN1A, ADAMTS9, and GADD45B-by using differentially expressed gene analysis and weighted gene co-expression network analysis method. The AUCs of these genes were all greater than 0.7 in the receiver operating characteristic curves analysis. The Gene Set Enrichment Analysis results demonstrated that mutual signaling pathways were mainly enriched in hypoxia and inflammatory response. CIBERSORT indicated that these seven hub genes were closely related to innate and adaptive immune cells. CONCLUSIONS We identified seven hub genes with promising diagnostic value and therapeutic targets in septic cirrhotic patients with sepsis-associated encephalopathy and/or hepatic encephalopathy. Hypoxia, inflammatory, and immunoreaction responses may share the common downstream pathways of the two common encephalopathies, for which earlier recognition and timely intervention are crucial for management of such septic cirrhotic patients in ICU.
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Affiliation(s)
- Juan Li
- Department of Intensive Care Unit, Hebei Key Laboratory of Critical Disease Mechanism and Intervention, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, Hebei, China
| | - Dong Yang
- Department of Emergency (Xiangjiang Hospital), The Third Hospital of Hebei Medical University, Shijiazhuang, 050051, Hebei, China
| | - Shengmei Ge
- Department of Intensive Care Unit, Hebei Key Laboratory of Critical Disease Mechanism and Intervention, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, Hebei, China
| | - Lixia Liu
- Department of Intensive Care Unit, Hebei Key Laboratory of Critical Disease Mechanism and Intervention, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, Hebei, China
| | - Yan Huo
- Department of Intensive Care Unit, Hebei Key Laboratory of Critical Disease Mechanism and Intervention, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, Hebei, China
| | - Zhenjie Hu
- Department of Intensive Care Unit, Hebei Key Laboratory of Critical Disease Mechanism and Intervention, The Fourth Hospital of Hebei Medical University, Shijiazhuang, 050011, Hebei, China.
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15
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Sacleux SC, Ichaï P, Coilly A, Boudon M, Lemaitre E, Sobesky R, De Martin E, Cailliez V, Kounis I, Poli E, Ordan MA, Pascale A, Duclos-Vallée JC, Feray C, Azoulay D, Vibert E, Cherqui D, Adam R, Samuel D, Saliba F. Liver transplant selection criteria and outcomes in critically ill patients with ACLF. JHEP Rep 2024; 6:100929. [PMID: 38074503 PMCID: PMC10703599 DOI: 10.1016/j.jhepr.2023.100929] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2023] [Revised: 08/30/2023] [Accepted: 09/13/2023] [Indexed: 03/26/2025] Open
Abstract
BACKGROUND & AIMS Retrospective studies have reported good results with liver transplantation (LTx) for acute-on-chronic liver failure (ACLF) in selected patients. The aim of this study was to evaluate the selection process for LTx in patients with ACLF admitted to the intensive care unit (ICU) and to assess outcomes. METHODS This prospective, non-interventional, single high-volume center study collected data on patients with ACLF admitted to the ICU between 2017-2020. RESULTS Among 200 patients (mean age: 55.0 ± 11.2 years and 74% male), 96 patients (48%) were considered potential candidates for LTx. Unfavourable addictology criteria (n = 76) was the main reason for LTx ineligibility. Overall, 69 patients were listed for LTx (34.5%) and 50 were transplanted (25% of the whole population). The 1-year survival in the LTx group was significantly higher than in the non-transplanted group (94% vs. 15%, p <0.0001). Among patients eligible for LTx, mechanical ventilation during the first 7 days of ICU stay and an increase in the number of organ failures at day 3 were associated with the absence of LTx or death (odds ratio 9.58; 95% CI 3.29-27.89; p <0.0001 for mechanical ventilation and odds ratio 1.87; 95% CI 1.08-3.24; p <0.027 for increasing organ failures). The probability of not being transplanted in patients with ACLF under mechanical ventilation is >85.4% in those experiencing an increase of 2 organ failures since admission or >91% if experiencing an increase >2 organ failures, at which point futility could be considered. CONCLUSION This prospective analysis of outcomes of patients with ACLF admitted to the ICU highlights the drastic nature of selection in this setting. Unfavourable addictology criteria, mechanical ventilation and increasing number of organ failures since admission were predictive of absence of LTx, futility and death. IMPACT AND IMPLICATIONS Liver transplantation (LT) is the best therapeutic option in selected cirrhotic patients admitted to the ICU with acute on chronic liver failure. However, the selection criteria are poorly described and based on retrospective studies. This is the first prospective study that aimed to describe the selection process for LT in a transplant center. Patients with ACLF should be admitted to the ICU and evaluated within a short period of time for LT. In the context of organ shortage, eligibility for LT and either absence of LT, futility of care or death are better clarified in our study. These are mainly determined by prolonged respiratory failure and worsening of organ failures since ICU admission. Considering worldwide variations in the etiology and definition of ACLF, transplant availability and a narrow therapeutic window for transplant further prospective studies are awaited.
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Affiliation(s)
- Sophie-Caroline- Sacleux
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Philippe Ichaï
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Audrey Coilly
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Marc Boudon
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Elise Lemaitre
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Rodolphe Sobesky
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Eleonora De Martin
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Valérie Cailliez
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Ilias Kounis
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Edoardo Poli
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Marie-Amélie Ordan
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Alina Pascale
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Jean-Charles Duclos-Vallée
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Cyrille Feray
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Daniel Azoulay
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Eric Vibert
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Daniel Cherqui
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - René Adam
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Didier Samuel
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
| | - Faouzi Saliba
- AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France
- University Paris Saclay, France
- INSERM Unit N°1193, Villejuif, France
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Sohail A, Naseem K, Khan A, Adhami T, Brown K. Predictors of inpatient outcomes of COVID-19 infection in patients with cirrhosis in the early pandemic phase: A nationwide survey. JGH Open 2023; 7:889-898. [PMID: 38162845 PMCID: PMC10757488 DOI: 10.1002/jgh3.12998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Revised: 08/25/2023] [Accepted: 10/25/2023] [Indexed: 01/03/2024]
Abstract
Background and Aim Previous studies conducted at single centers have suggested that patients with cirrhosis are at a greater risk for worse outcomes with COVID-19. However, there is limited data on a national level in the United States. We aimed to study hospital-related outcomes and identify the predictors of poor outcomes in patients with cirrhosis and concurrent COVID-19. Methods We queried 2020 National Inpatient and Readmission databases to identify all hospitalizations due to cirrhosis in adults with a diagnosis of COVID-19. Primary outcomes included inpatient mortality, mechanical ventilation (MV), and intensive care unit (ICU) utilization. Secondary outcomes included mean length of stay (LOS) and mean hospitalization costs. We classified cirrhosis into compensated (CC) and decompensated (DC) groups. Results We identified 25194 hospitalizations of adult patients due to cirrhosis with a concurrent diagnosis of COVID-19. These patients had higher mortality (19.50% vs 6.19%, P ≤ 0.01), MV (11.7% vs 2.8%, P ≤ 0.01), ICU utilization (17.3% vs 8.1%, P ≤ 0.01), LOS (8.89 days vs 6.16 days, P ≤ 0.01), and total hospitalization costs ($24 817 vs $18 505, P ≤ 0.01) than those without COVID-19. On subgroup analysis, patients in the DC group had higher mortality, LOS, and hospitalization costs compared to those in the CC group. On multivariate analysis, we also found that COVID-19 infection, age, Charlson Comorbidity Index ≥3, acute kidney injury, end-stage renal disease, septic shock, acute respiratory failure, MV, and ICU status were independent predictors for mortality. Conclusion Our study suggests that COVID-19 infection is an independent predictor of mortality in patients with cirrhosis, with threefold higher mortality and increased resource utilization. Early intervention through immunizations and advanced COVID-19 therapies can help improve these outcomes.
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Affiliation(s)
- Abdullah Sohail
- Department of Internal MedicineUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
| | | | - Ahmad Khan
- Department of Gastroenterology and HepatologyCase Western Reserve UniversityClevelandOhioUSA
| | | | - Kyle Brown
- Department of Internal MedicineUniversity of Iowa Hospitals and ClinicsIowa CityIowaUSA
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Essing T, Bock H, Wieland B, Fluegen G, Bednarsch J, Bode JG, Neumann UP, Roderburg C, Loosen SH, Luedde T. Clinical determinants of hospital mortality in liver failure: a comprehensive analysis of 62,717 patients. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1472-1483. [PMID: 36972596 DOI: 10.1055/a-2016-9061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Liver failure (LF) is characterised by a loss of the synthetic and metabolic liver function and is associated with a high mortality. Large-scale data on recent developments and hospital mortality of LF in Germany are missing. A systematic analysis and careful interpretation of these datasets could help to optimise outcomes of LF. METHODS We used standardised hospital discharge data of the Federal Statistical Office to evaluate current trends, hospital mortality and factors associated with an unfavourable course of LF in Germany between 2010 and 2019. RESULTS A total of 62,717 hospitalised LF cases were identified. Annual LF frequency decreased from 6716 (2010) to 5855 (2019) cases and was higher among males (60.51%). Hospital mortality was 38.08% and significantly declined over the observation period. Mortality significantly correlated with patients' age and was highest among individuals with (sub)acute LF (47.5%). Multivariate regression analyses revealed pulmonary (ORARDS: 2.76, ORmechanical ventilation: 6.46) and renal complications (ORacute kidney failure: 2.04, ORhepatorenal syndrome: 2.92) and sepsis (OR: 1.92) as factors for increased mortality. Liver transplantation reduced mortality in patients with (sub)acute LF. Hospital mortality significantly decreased with the annual LF case volume and ranged from 47.46% to 29.87% in low- or high-case-volume hospitals, respectively. CONCLUSIONS Although incidence rates and hospital mortality of LF in Germany have constantly decreased, hospital mortality has remained at a very high level. We identified a number of variables associated with increased mortality that could help to improve framework conditions for the treatment of LF in the future.
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Affiliation(s)
- Tobias Essing
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Paracelsus Medical University, Klinikum Nürnberg, Nürnberg, Germany
| | - Hans Bock
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Björn Wieland
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Georg Fluegen
- Department of Surgery (A), University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jan Bednarsch
- Department of Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Johannes G Bode
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ulf P Neumann
- Department of Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Christoph Roderburg
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Sven H Loosen
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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18
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Kou Y, Yang Y, Du S, Liu X, He K, Yuan W, Nie B. Risk factors for the development of sepsis in patients with cirrhosis in intensive care units. Clin Transl Sci 2023; 16:1748-1757. [PMID: 37226657 PMCID: PMC10582674 DOI: 10.1111/cts.13549] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2023] [Revised: 04/28/2023] [Accepted: 05/12/2023] [Indexed: 05/26/2023] Open
Abstract
Sepsis is a serious complication of liver cirrhosis. This study aimed to develop a risk prediction model for sepsis among patients with liver cirrhosis. A total of 3130 patients with liver cirrhosis were enrolled from the Medical Information Mart for Intensive Care IV database, and randomly assigned into training and validation cohorts in a 7:3 ratio. The least absolute shrinkage and selection operator (LASSO) regression was used to filter variables and select predictor variables. Multivariate logistic regression was used to establish the prediction model. Based on LASSO and multivariate logistic regression, gender, base excess, bicarbonate, white blood cells, potassium, fibrinogen, systolic blood pressure, mechanical ventilation, and vasopressor use were identified as independent risk variables, and then a nomogram was constructed and validated. The consistency index (C-index), receiver operating characteristic curve, calibration curve, and decision curve analysis (DCA) were used to measure the predictive performance of the nomogram. As a result of the nomogram, good discrimination was achieved, with C-indexes of 0.814 and 0.828 for the training and validation cohorts, respectively, and an area under the curve of 0.849 in the training cohort and 0.821 in the validation cohort. The calibration curves demonstrated good agreement between the predictions and observations. The DCA curves showed the nomogram had significant clinical value. We developed and validated a risk-prediction model for sepsis in patients with liver cirrhosis. This model can assist clinicians in the early detection and prevention of sepsis in patients with liver cirrhosis.
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Affiliation(s)
- Yan‐qi Kou
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
| | - Yu‐ping Yang
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
- Department of Gastroenterology, Affiliated Hospital of Guangdong Medical UniversityGuangdong Medical UniversityZhanjiangChina
| | - Shen‐shen Du
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
| | - Xiongxiu Liu
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
| | - Kun He
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
| | - Wei‐nan Yuan
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
| | - Biao Nie
- Department of GastroenterologyThe First Affiliated Hospital of Jinan UniversityJinan UniversityGuangzhouChina
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19
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Pensier J, De Jong A, Monet C, Aarab Y, Le Bihan C, Capdevila M, Lakbar I, Stock L, Belafia F, Chanques G, Molinari N, Jaber S. Outcomes and time trends of acute respiratory distress syndrome patients with and without liver cirrhosis: an observational cohort. Ann Intensive Care 2023; 13:96. [PMID: 37773241 PMCID: PMC10541379 DOI: 10.1186/s13613-023-01190-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/14/2023] [Accepted: 09/18/2023] [Indexed: 10/01/2023] Open
Abstract
BACKGROUND In studies prior to lung-protective ventilation, liver cirrhosis in acute respiratory distress syndrome (ARDS) was associated with high mortality rates. Since patients with cirrhosis have been excluded from many trials on ARDS, their outcome when treated with lung-protective ventilation is unclear. The objectives were to assess whether cirrhosis is associated with mortality in ARDS and trends over time in mortality and severity. METHODS We conducted a retrospective analysis of a prospective observational cohort conducted in a 20-bed tertiary ICU from October 2003 to December 2021. All consecutive adult critically ill patients with ARDS were included. ARDS was defined by the Berlin criteria. The primary outcome was 90 day mortality, assessed with Kaplan-Meier curves and multivariate Cox analysis. Time trends were assessed on 90 day mortality, Sequential Organ-Function Assessment score (SOFA) and non-hepatic SOFA. Ventilation settings were compared between patients with and without cirrhosis. RESULTS Of the 7155 patients screened, 863 had a diagnosis of ARDS. Among these ARDS patients, 157(18%) had cirrhosis. The overall 90 day mortality was of 43% (378/863), 57% (90/157) in patients with cirrhosis and 41% (288/706) in patients without cirrhosis (p < 0.001). On survival curves, cirrhosis was associated with 90 day mortality (p < 0.001). Cirrhosis was independently associated with 90 day mortality in multivariate analysis (hazard ratio = 1.56, 95% confidence interval 1.20-2.02). There was no change in mortality over time in ARDS patients with and without cirrhosis. SOFA (p = 0.04) and non-hepatic SOFA (p = 0.02) increased over time in ARDS patients without cirrhosis, and remained stable in ARDS patients with cirrhosis. Tidal volume, positive end-expiratory pressure, plateau pressure and driving pressure were not different between ARDS patients with and without cirrhosis. CONCLUSIONS Although ARDS management improved over the last decades, the 90 day mortality remained high and stable over time for both ARDS patients with (57%) and without cirrhosis (41%). Nevertheless, the severity of patients without cirrhosis has increased over time, while the severity of patients with cirrhosis has remained stable.
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Affiliation(s)
- Joris Pensier
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, 80 Avenue Augustin Fliche, Montpellier Cedex 5, Montpellier, France
- Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, France
| | - Audrey De Jong
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, 80 Avenue Augustin Fliche, Montpellier Cedex 5, Montpellier, France
- Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, France
| | - Clément Monet
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, 80 Avenue Augustin Fliche, Montpellier Cedex 5, Montpellier, France
- Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, France
| | - Yassir Aarab
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, 80 Avenue Augustin Fliche, Montpellier Cedex 5, Montpellier, France
| | - Clément Le Bihan
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, 80 Avenue Augustin Fliche, Montpellier Cedex 5, Montpellier, France
| | - Mathieu Capdevila
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, 80 Avenue Augustin Fliche, Montpellier Cedex 5, Montpellier, France
- Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, France
| | - Inès Lakbar
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, 80 Avenue Augustin Fliche, Montpellier Cedex 5, Montpellier, France
- CEReSS, Health Service Research and Quality of Life Centre, School of Medicine, Aix-Marseille University, La Timone, Marseille, France
| | - Lucas Stock
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, 80 Avenue Augustin Fliche, Montpellier Cedex 5, Montpellier, France
| | - Fouad Belafia
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, 80 Avenue Augustin Fliche, Montpellier Cedex 5, Montpellier, France
| | - Gerald Chanques
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, 80 Avenue Augustin Fliche, Montpellier Cedex 5, Montpellier, France
- Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, France
| | - Nicolas Molinari
- Medical Information, IMAG; CNRS, Univ Montpellier, Centre Hospitalier Regional Universitaire de Montpellier, Montpellier, France
- Institut Desbrest de Santé Publique (IDESP), INSERM-Université de Montpellier. Département d'informatique Médicale, CHRU Montpellier, Montpellier, France
| | - Samir Jaber
- Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, INSERM U1046, 1, 80 Avenue Augustin Fliche, Montpellier Cedex 5, Montpellier, France.
- Centre Hospitalier Universitaire Montpellier, 34295, Montpellier, France.
- Samir JABER, Département d'Anesthésie Réanimation B (DAR B), 80 Avenue Augustin Fliche, 34295, Montpellier, France.
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20
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Perricone G, Artzner T, De Martin E, Jalan R, Wendon J, Carbone M. Intensive care management of acute-on-chronic liver failure. Intensive Care Med 2023; 49:903-921. [PMID: 37552333 DOI: 10.1007/s00134-023-07149-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2023] [Accepted: 06/21/2023] [Indexed: 08/09/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined by an acute deterioration of the liver function associated with extrahepatic organ failures requiring intensive care support and associated with a high short-term mortality. ACLF has emerged as a major cause of mortality in patients with cirrhosis and chronic liver disease. ACLF has a unique pathophysiology in which systemic inflammation plays a key role; this provides the basis of novel therapies, several of which are now in clinical trials. Intensive care unit (ICU) therapy parallels that applied in the general ICU population in some organ failures but has peculiar differential characteristics in others. Critical care management strategies and the option of liver transplantation (LT) should be balanced with futility considerations in those with a poor prognosis. Nowadays, LT is the only life-saving treatment that can radically improve the long-term prognosis of patients with ACLF. This narrative review will provide insights on the current understanding of ACLF with emphasis on intensive care management.
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Affiliation(s)
- Giovanni Perricone
- Hepatology and Gastroenterology Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy.
| | - Thierry Artzner
- Hôpitaux Universitaires de Strasbourg, 67000, Strasbourg, France
| | - Eleonora De Martin
- AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris-Saclay, Villejuif, France
| | - Rajiv Jalan
- Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK
- European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Julia Wendon
- Liver Intensive Therapy Unit, Division of Inflammation Biology, King's College London, London, UK
| | - Marco Carbone
- Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
- European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy
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21
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Maiwall R, Rao Pasupuleti SS, Hidam AK, Kumar A, Tevethia HV, Vijayaraghavan R, Majumdar A, Prasher A, Thomas S, Mathur RP, Kumar G, Sarin SK. A randomised-controlled trial (TARGET-C) of high vs. low target mean arterial pressure in patients with cirrhosis and septic shock. J Hepatol 2023; 79:349-361. [PMID: 37088310 DOI: 10.1016/j.jhep.2023.04.006] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2022] [Revised: 03/17/2023] [Accepted: 04/04/2023] [Indexed: 04/25/2023]
Abstract
BACKGROUND & AIMS A high mean arterial pressure (MAP) target has been associated with improved renal outcomes in patients with cirrhosis, though it has not been studied in critically ill patients with cirrhosis and septic shock (CICs). We compared the efficacy of a high (80-85 mmHg; H-MAP) vs. low (60-65; L-MAP) target MAP strategy in improving 28-day mortality in CICs. METHODS We performed open-label 1:1 randomisation of 150 CICs (H-MAP 75; L-MAP 75). The primary endpoint was 28-day mortality and secondary endpoints included reversal of shock, acute kidney injury (AKI) at day 5, the incidence of intradialytic hypotension (IDH), and adverse events. Endothelial markers were analysed in a subset of patients. RESULTS The baseline characteristics were comparable. On intention-to-treat analysis, 28-day mortality (65% vs. 56%; p = 0.54), reversal of shock (47% vs. 53%; p = 0.41) and AKI development (45% vs. 31%;p = 0.06) were not different between the H-MAP and L-MAP groups, respectively. A lower incidence of IDH (12% vs. 48%; p <0.001) and higher adverse events necessitating protocol discontinuation (24% vs. 11%; p = 0.031) were noted in the H-MAP group. On per-protocol analysis (L-MAP 67; H-MAP 57), a significantly higher reversal of AKI (53% vs. 31%; p = 0.02) and a lower incidence of IDH (4% vs. 53%; p <0.001) were observed in the H-MAP group. Endothelial repair markers such as ADAMTS (2.11 ± 1.13 vs. 1.15 ± 0.48; p = 0.002) and angiopoietin-2 (74.08 ± 53.00 vs. 41.80 ± 15.95; p = 0.016) were higher in the H-MAP group. CONCLUSIONS A higher MAP strategy does not confer a survival benefit in CICs, but improves tolerance to dialysis, lactate clearance and renal recovery. Higher adverse events indicate the need for better tools to evaluate target microcirculation pressures in CICs. IMPACT AND IMPLICATIONS Maintaining an appropriate organ perfusion pressure during sepsis is the ultimate goal of haemodynamic management. A higher mean arterial pressure (MAP) improves renal outcomes in patients with hepatorenal syndrome. Patients with cirrhosis and septic shock have severe circulatory disturbances, low MAP, and poor tissue perfusion. In these patients, targeting higher MAP vs. lower MAP does not confer any survival benefit but is associated with more adverse events. A higher target strategy was associated with better tolerance and lesser episodes of hypotension on dialysis. Patients who could achieve the higher target MAP, without the development of adverse events, had improved renal outcomes and better lactate clearance. Higher MAP was also associated with improvements in markers of endothelial function. A higher target MAP strategy, with close monitoring of adverse events, may be recommended for patients with cirrhosis and septic shock. CLINICAL TRIAL NUMBER NCT03145168.
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Affiliation(s)
- Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Samba Siva Rao Pasupuleti
- Department of Statistics, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, India; Department of Applied Mathematics and Statistics, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, India
| | - Ashini Kumar Hidam
- Department of Clinical and Molecular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Anupam Kumar
- Department of Clinical and Molecular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Rajan Vijayaraghavan
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Arpita Majumdar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Adarsh Prasher
- Department of Clinical and Molecular Medicine, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Sherin Thomas
- Department of Biochemistry, Institute of Liver and Biliary Sciences, New Delhi, India
| | | | - Guresh Kumar
- Department of Statistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv Kumar Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India.
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22
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Dukewich M, Liu CH, Weinberg EM, Mahmud N, Reddy KR. Clinical Predictors of Intensive Care Unit Transfer in Admitted Patients with Cirrhosis. Dig Dis Sci 2023; 68:2344-2359. [PMID: 36781572 PMCID: PMC10192086 DOI: 10.1007/s10620-023-07856-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 01/28/2023] [Indexed: 02/15/2023]
Abstract
BACKGROUND Patients with cirrhosis are at high risk of mortality after organ failure that requires ICU care. There have been attempts to predict which patients are at highest risk, with some success found in adapting liver disease-specific scoring systems with clinical variables commonly associated with critical illness. However, the clinical factors predictive of which patients with cirrhosis are most at-risk of needing ICU level care are unknown. AIMS Our study set out to better understand which clinical variables were associated with need for ICU care in patients with cirrhosis. METHODS Retrospective analysis of admitted patients with cirrhosis at single tertiary care center. RESULTS Patients with cirrhosis admitted to our center were categorized into three groups: those without ICU transfer, those admitted to the ICU directly from the emergency department (ED), and those admitted to the ICU from the medicine floor. These groups differed in mortality at 30 days (3.5% vs. 15% vs. 25%, P < 0.001) and at subsequent intervals up to 1 year. These groups differed in indication for ICU transfer, with GI bleed, hemorrhagic shock, hepatic encephalopathy, and hyponatremia occurring more in the ED-to-ICU group, while respiratory failure was more common in the floor-to-ICU group. In multivariable analysis, factors associated with ICU transfer included worsened kidney function, anemia, hyponatremia, leukocytosis, and the decision to obtain a lactate level. Similar analysis with only floor-to-ICU patients found that ICU transfer was associated with hypoalbuminemia, hyponatremia, hypotension, and SIRS score. CONCLUSION Our study found significant differences in mortality among three distinct groups of patients with cirrhosis. A risk factor model for ICU transfer found that variables both specific and nonspecific to liver disease were associated with ICU transfer, with between-group differences supporting the idea of different clinical phenotypes and suggesting factors that should be considered in early triage and assessment of hospitalized patients with cirrhosis.
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Affiliation(s)
- Matthew Dukewich
- Department of Medicine, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - Chung-Heng Liu
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Ethan M Weinberg
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
- Perelman Center for Advanced Medicine, South Pavilion 4th Floor, 3400 Civic Center Blvd, Philadelphia, PA, 19104, USA.
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
| | - K Rajender Reddy
- Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA
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23
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Reverter E, Toapanta D, Bassegoda O, Zapatero J, Fernandez J. Critical Care Management of Acute-on-Chronic Liver Failure: Certainties and Unknowns. Semin Liver Dis 2023; 43:206-217. [PMID: 37369227 DOI: 10.1055/s-0043-1769907] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/29/2023]
Abstract
Intensive care unit (ICU) admission is frequently required in patients with decompensated cirrhosis for organ support. This entity, known as acute-on-chronic liver failure (ACLF), is associated with high short-term mortality. ICU management of ACLF is complex, as these patients are prone to develop new organ failures and infectious or bleeding complications. Poor nutritional status, lack of effective liver support systems, and shortage of liver donors are also factors that contribute to increase their mortality. ICU therapy parallels that applied in the general ICU population in some complications but has differential characteristics in others. This review describes the current knowledge on critical care management of patients with ACLF including organ support, prognostic assessment, early liver transplantation, and futility rules. Certainties and knowledge gaps in this area are also discussed.
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Affiliation(s)
- Enric Reverter
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - David Toapanta
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Octavi Bassegoda
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Juliana Zapatero
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
| | - Javier Fernandez
- Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS and CIBEREHD, University of Barcelona, Barcelona, Spain
- European Foundation for the Study of Chronic Liver Failure, EASL-CLIF, Consortium, Barcelona, Spain
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24
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Maccauro V, Airola C, Santopaolo F, Gasbarrini A, Ponziani FR, Pompili M. Gut Microbiota and Infectious Complications in Advanced Chronic Liver Disease: Focus on Spontaneous Bacterial Peritonitis. Life (Basel) 2023; 13:life13040991. [PMID: 37109520 PMCID: PMC10145455 DOI: 10.3390/life13040991] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 03/28/2023] [Accepted: 04/01/2023] [Indexed: 04/29/2023] Open
Abstract
Liver cirrhosis is a chronic disease that can be complicated by episodes of decompensation such as variceal bleeding, hepatic encephalopathy, ascites, and jaundice, with subsequent increased mortality. Infections are also among the most common complications in cirrhotic patients, mostly due to a defect in immunosurveillance. Among them, one of the most frequent is spontaneous bacterial peritonitis (SBP), defined as the primary infection of ascitic fluid without other abdominal foci. SBP is mainly induced by Gram-negative bacteria living in the intestinal tract, and translocating through the intestinal barrier, which in cirrhotic patients is defective and more permeable. Moreover, in cirrhotic patients, the intestinal microbiota shows an altered composition, poor in beneficial elements and enriched in potentially pathogenic ones. This condition further promotes the development of leaky gut and increases the risk of SBP. The first-line treatment of SBP is antibiotic therapy; however, the antibiotics used have a broad spectrum of action and may adversely affect the composition of the gut microbiota, worsening dysbiosis. For this reason, the future goal is to use new therapeutic agents that act primarily on the gut microbiota, selectively modulating it, or on the intestinal barrier, reducing its permeability. In this review, we aim to describe the reciprocal relationship between gut microbiota and SBP, focusing on pathogenetic aspects but also on new future therapies.
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Affiliation(s)
- Valeria Maccauro
- Internal Medicine and Gastroenterology-Hepatology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
| | - Carlo Airola
- Internal Medicine and Gastroenterology-Hepatology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
| | - Francesco Santopaolo
- Internal Medicine and Gastroenterology-Hepatology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
| | - Antonio Gasbarrini
- Internal Medicine and Gastroenterology-Hepatology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Department of Translational Medicine and Surgery, Catholic University, Largo Francesco Vito 1, 00168 Roma, Italy
| | - Francesca Romana Ponziani
- Internal Medicine and Gastroenterology-Hepatology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Department of Translational Medicine and Surgery, Catholic University, Largo Francesco Vito 1, 00168 Roma, Italy
| | - Maurizio Pompili
- Internal Medicine and Gastroenterology-Hepatology Unit, Fondazione Policlinico Universitario Agostino Gemelli IRCCS, 00168 Roma, Italy
- Department of Translational Medicine and Surgery, Catholic University, Largo Francesco Vito 1, 00168 Roma, Italy
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25
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Schult D, Rasch S, Schmid RM, Lahmer T, Mayr U. EASIX Is an Accurate and Easily Available Prognostic Score in Critically Ill Patients with Advanced Liver Disease. J Clin Med 2023; 12:jcm12072553. [PMID: 37048641 PMCID: PMC10094870 DOI: 10.3390/jcm12072553] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2023] [Revised: 03/18/2023] [Accepted: 03/22/2023] [Indexed: 03/31/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is associated with high mortality. Objective prognostic scores are important for treatment decisions. EASIX (Endothelial Activation and Stress Index) is a simple biomarker consisting of LDH, platelets, and creatinine, reflecting endothelial dysfunction after allogeneic stem cell transplantation. Considering endothelial dysfunction in the pathogenesis of ACLF, this study aimed to test the discriminative ability of EASIX in advanced liver disease. We retrospectively analysed the prognostic potential of EASIX to predict 28-day and 3-month mortality in a total of 188 liver cirrhotic patients requiring treatment at the intensive care unit. We evaluated the ability of EASIX to rule out early infections and predict the need for hemodialysis. EASIX performed moderately better than established scores in predicting 28-day mortality (AUC = 0.771) and was nearly equivalent (AUC = 0.791) to SOFA and APACHE-II in the prediction of 3-month mortality. Importantly, EASIX showed better diagnostic potential in ruling out clinically apparent infections than common proinflammatory markers (AUC = 0.861, p < 0.001) and showed suitable accuracy in predicting the need for hemodialysis (AUC = 0.833). EASIX is an accurate, objective and easily assessable biomarker for predicting mortality and complications in patients with advanced liver disease.
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26
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Colling K, Kraft AK, Harry ML. Alcohol use disorder in the intensive care unit a highly morbid condition, but chemical dependency discussion improves outcomes. Acute Crit Care 2023; 38:122-133. [PMID: 36935541 PMCID: PMC10030241 DOI: 10.4266/acc.2022.00584] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2022] [Revised: 09/22/2022] [Accepted: 09/23/2022] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Alcohol use disorders (AUD) are common in patients admitted to intensive care units (ICU) and increase the risk for worse outcomes. In this study, we describe factors associated with patient mortality after ICU admission and the effect of chemical dependency (CD) counseling on outcomes in the year following ICU admission. METHODS We retrospectively reviewed patient demographics, hospital data, and documentation of CD counseling by medical providers for all ICU patients with AUD admitted to our institution between January 2017 and March 2019. Primary outcomes were in-hospital and 1-year mortality. RESULTS Of the 527 patients with AUD requiring ICU care, median age was 56 years (range, 18-86). Both in-hospital (12%) and 1-year mortality rates (27%) were high. Rural patients, comorbidities, older age, need for mechanical ventilation, and complications were associated with increased risk of in-hospital and 1-year mortality. CD counseling was documented for 73% of patients, and 50% of these patients accepted alcohol treatment or resources prior to discharge. CD evaluation and acceptance was associated with a significantly decreased rate of readmission for liver or alcohol-related issues (36% vs. 58%; odds ratio [OR], 0.41; 95% confidence interval [CI], 0.27-0.61) and 1-year mortality (7% vs. 19.5%; OR, 0.32; 95% CI, 0.16-0.64). CD evaluation alone, regardless of patient acceptance, was associated with a significantly decreased 1-year post-discharge mortality rate (12% vs. 23%; OR, 0.44; 95% CI, 0.25-0.77). CONCLUSIONS ICU patients with AUD had high in-hospital and 1-year mortality. CD evaluation, regardless of patient acceptance, was associated with a significant decrease in 1-year mortality.
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Affiliation(s)
- Kristin Colling
- Department of Trauma Surgery, St. Mary’s Medical Center-Essentia Health, Duluth, MN, USA
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
| | - Alexandra K. Kraft
- Department of Surgery, University of Minnesota Medical School, Minneapolis, MN, USA
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Schulz MS, Mengers J, Gu W, Drolz A, Ferstl PG, Amoros A, Uschner FE, Ackermann N, Guttenberg G, Queck A, Brol MJ, Graf C, Stoffers P, de la Vera ALL, Cremonese C, Erasmus HP, Welker MW, Grünewaldt A, Arroyo V, Bojunga J, Fernandez J, Zeuzem S, Kluwe J, Peiffer KH, Welsch C, Fuhrmann V, Rohde G, Trebicka J. Pulmonary impairment independently determines mortality in critically ill patients with acute-on-chronic liver failure. Liver Int 2023; 43:180-193. [PMID: 35727853 DOI: 10.1111/liv.15343] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2021] [Revised: 05/26/2022] [Accepted: 06/19/2022] [Indexed: 01/04/2023]
Abstract
BACKGROUND & AIMS In ACLF patients, an adequate risk stratification is essential, especially for liver transplant allocation, since ACLF is associated with high short-term mortality. The CLIF-C ACLF score is the best prognostic model to predict outcome in ACLF patients. While lung failure is generally regarded as signum malum in ICU care, this study aims to evaluate and quantify the role of pulmonary impairment on outcome in ACLF patients. METHODS In this retrospective study, 498 patients with liver cirrhosis and admission to IMC/ICU were included. ACLF was defined according to EASL-CLIF criteria. Pulmonary impairment was classified into three groups: unimpaired ventilation, need for mechanical ventilation and defined pulmonary failure. These factors were analysed in different cohorts, including a propensity score-matched ACLF cohort. RESULTS Mechanical ventilation and pulmonary failure were identified as independent risk factors for increased short-term mortality. In matched ACLF patients, the presence of pulmonary failure showed the highest 28-day mortality (83.7%), whereas mortality rates in ACLF with mechanical ventilation (67.3%) and ACLF without pulmonary impairment (38.8%) were considerably lower (p < .001). Especially in patients with pulmonary impairment, the CLIF-C ACLF score showed poor predictive accuracy. Adjusting the CLIF-C ACLF score for the grade of pulmonary impairment improved the prediction significantly. CONCLUSIONS This study highlights that not only pulmonary failure but also mechanical ventilation is associated with worse prognosis in ACLF patients. The grade of pulmonary impairment should be considered in the risk assessment in ACLF patients. The new score may be useful in the selection of patients for liver transplantation.
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Affiliation(s)
- Martin S Schulz
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany.,Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Jan Mengers
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Wenyi Gu
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany.,Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Andreas Drolz
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Philip G Ferstl
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Alex Amoros
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
| | - Frank E Uschner
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany.,Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Nora Ackermann
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Georg Guttenberg
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Alexander Queck
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Maximilian J Brol
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany.,Department of Internal Medicine B, University of Münster, Münster, Germany
| | - Christiana Graf
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Philipp Stoffers
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | | | - Carla Cremonese
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Hans-Peter Erasmus
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Martin W Welker
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Achim Grünewaldt
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Vincente Arroyo
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
| | - Jörg Bojunga
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Javier Fernandez
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain.,Hospital Clinic of Barcelona, University of Barcelona, CIBEReHD, IDIBAPS, Barcelona, Spain
| | - Stefan Zeuzem
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Johannes Kluwe
- 1st Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | | | - Christoph Welsch
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Valentin Fuhrmann
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gernot Rohde
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany
| | - Jonel Trebicka
- Department of Internal Medicine I, Goethe University, Frankfurt, Germany.,Department of Internal Medicine B, University of Münster, Münster, Germany.,European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
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Luxenburger H, Schmidt K, Biever P, Supady A, Sekandarzad A, Roehlen N, Reincke M, Neumann-Haefelin C, Schultheiss M, Wengenmayer T, Thimme R, Bettinger D. Survival prediction using the Freiburg index of post-TIPS survival (FIPS) in critically ill patients with acute- on chronic liver failure: A retrospective observational study. Front Med (Lausanne) 2022; 9:1042674. [PMID: 36619640 PMCID: PMC9812953 DOI: 10.3389/fmed.2022.1042674] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
Background and aim Liver cirrhosis in patients treated in the intensive care unit (ICU) is associated with high mortality. Well established scores are useful to allow for assessment of prognosis and support ICU treatment guidance. However, currently used scoring systems often do not reflect the complexity of critically ill patients. Therefore, we tested the newly developed Freiburg index-of post-TIPS survival (FIPS) score in order to assess its potential role for prognostication of cirrhotic patients in the ICU. Methods A total of 310 patients with liver cirrhosis treated in the ICU between 2010 and 2021 were enrolled in this retrospective observational study. Prognostic factors for mortality and 28-day mortality were assessed. Moreover, using c indices the prognostic discrimination of different prognostic scores was analyzed. Results The FIPS score allowed to discriminate patients with high ICU mortality and within 28-days after ICU treatment (ICU mortality: 42.2 vs. 59.9%, p = 0.008 and 28-day mortality: 43.3 vs. 74.1%, p < 0.001). However, the FIPS score in its current composition showed no superior prognostic discrimination compared to other established scores. Multivariable analyses identified the FIPS score (HR 1.25 [1.04-1.49], p = 0.015) and lactate at admission (HR 1.07 [1.04-1.09], p < 0.001) as significant predictors of ICU mortality. Lactate at admission substantially improved patient risk stratification within each FIPS risk groups. Conclusion Similar to other commonly used scores, the FIPS score in its current composition does not allow a sufficiently reliable prognostication of critically ill patients treated in the ICU. However, adding lactate as additional factor to the FIPS score may improve its prognostic ability.
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Affiliation(s)
- Hendrik Luxenburger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,IMM-PACT, Medizinische Fakultät, Albert-Ludwigs-Universität Freiburg, Freiburg im Breisgau, Germany
| | - Katharina Schmidt
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Paul Biever
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Alexander Supady
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Asieb Sekandarzad
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Natascha Roehlen
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Marlene Reincke
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Christoph Neumann-Haefelin
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Michael Schultheiss
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Tobias Wengenmayer
- Interdisciplinary Medical Intensive Care, Faculty of Medicine, University Medical Center–University of Freiburg, Freiburg im Breisgau, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, Freiburg im Breisgau, Germany,*Correspondence: Dominik Bettinger,
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Gibbs JT, Louissaint J, Tapper EB. Rate of Successful Extubation in Mechanically Ventilated Patients with Cirrhosis and Hepatic Coma. Dig Dis Sci 2022; 67:5336-5344. [PMID: 35107648 PMCID: PMC9343472 DOI: 10.1007/s10620-022-07400-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2021] [Accepted: 01/15/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND The prognosis of critically ill patients with cirrhosis who require mechanical ventilation is guarded. Data are lacking for the optimal therapeutic approach to hepatic encephalopathy (HE) in the ventilated patient. METHODS Retrospective cohort analysis of 314 encounters (298 patients) with cirrhosis who underwent mechanical ventilation in a medical ICU and were ordered at least 1 dose of lactulose. Hazard of extubation alive was determined using a competing risk model. Primary exposures were HE therapy (lactulose and rifaximin) which were adjusted for the indication for ventilation (HE, procedures, respiratory failure), age, MELD-Na, and compensation status. RESULTS Indications for ventilation were 22.3% for grade 4 HE, 29.9% for procedures, and 47.8% for respiratory or cardiovascular failure. Median length of intubation was 2.63 days; death rate on ventilator was 31.2%. Relative to intubation for procedure, hazard of extubation for intubation for HE was 0.34 (95% confidence interval (CI): 0.22-0.52) and 0.33 (CI: 0.23-0.47) for respiratory failure. Hazard of extubation for rifaximin administration within 24-h after intubation was significant at 1.74 (1.21-2.50). Lactulose dosing was not significant for hazard of extubation. DISCUSSION Mortality is high for all patients with cirrhosis requiring mechanical ventilation, including those intubated for grade 4 HE. Efforts to optimize the odds of successful extubation are urgently needed. Our findings suggest improved incidence of extubation associated with rifaximin administration in the first 24-h after intubation. Prospective, multi-center data to confirm these findings in this vulnerable population are warranted.
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Affiliation(s)
- Jeffrey T Gibbs
- Department of Internal Medicine, University of Michigan Health System, 3116 Taubman Center, SPC 5368, 1500 E Medical Center Dr., Ann Arbor, MI, 48109, USA.
| | - Jeremy Louissaint
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
| | - Elliot B Tapper
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
- Gastroenterology Section, VA Ann Arbor Healthcare System, Ann Arbor, MI, USA
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30
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Zhang W, Zhang Y, Liu Q, Nie Y, Zhu X. Development and validation of a prognostic nomogram for decompensated liver cirrhosis. World J Clin Cases 2022; 10:10467-10477. [PMID: 36312496 PMCID: PMC9602236 DOI: 10.12998/wjcc.v10.i29.10467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/30/2022] [Revised: 08/31/2022] [Accepted: 09/09/2022] [Indexed: 02/05/2023] Open
Abstract
BACKGROUND Decompensated liver cirrhosis (DLC) is a stage in the progression of liver cirrhosis and has a high mortality.
AIM To establish and validate a novel and simple-to-use predictive nomogram for evaluating the prognosis of DLC patients.
METHODS A total of 493 patients with confirmed DLC were enrolled from The First Affiliated Hospital of Nanchang University (Nanchang, Jiangxi Province, China) between December 2013 and August 2019. The patients were divided into two groups: a derivation group (n = 329) and a validation group (n = 164). Univariate and multivariate Cox regression analyses were performed to assess prognostic factors. The performance of the nomogram was determined by its calibration, discrimination, and clinical usefulness.
RESULTS Age, mechanical ventilation application, model for end-stage liver disease (MELD) score, mean arterial blood pressure, and arterial oxygen partial pressure/inhaled oxygen concentration were used to construct the model. The C-indexes of the nomogram in the derivation and validation groups were 0.780 (95%CI: 0.670-0.889) and 0.792 (95%CI: 0.698-0.886), respectively. The calibration curve exhibited good consistency with the actual observation curve in both sets. In addition, decision curve analysis indicated that our nomogram was useful in clinical practice.
CONCLUSION A simple-to-use novel nomogram based on a large Asian cohort was established and validated and exhibited improved performance compared with the Child-Turcotte-Pugh and MELD scores. For patients with DLC, the proposed nomogram may be helpful in guiding clinicians in treatment allocation and may assist in prognosis prediction.
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Affiliation(s)
- Wang Zhang
- Department of Gastroenterology, Jiangxi Clinical Research Center for Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Yue Zhang
- Department of Gastroenterology, Jiangxi Clinical Research Center for Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Qi Liu
- Department of Gastroenterology, Jiangxi Clinical Research Center for Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Yuan Nie
- Department of Gastroenterology, Jiangxi Clinical Research Center for Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
| | - Xuan Zhu
- Department of Gastroenterology, Jiangxi Clinical Research Center for Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, Jiangxi Province, China
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31
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Are Cirrhotic Patients Receiving Invasive Mechanical Ventilation at Risk of Abundant Microaspiration. J Clin Med 2022; 11:jcm11205994. [PMID: 36294314 PMCID: PMC9604551 DOI: 10.3390/jcm11205994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2022] [Revised: 09/26/2022] [Accepted: 10/06/2022] [Indexed: 11/23/2022] Open
Abstract
Previous studies have identified cirrhosis as a risk factor for ventilator-associated pneumonia (VAP). The aim of our study was to determine the relationship between cirrhosis and abundant gastric-content microaspiration in intubated critically ill patients. We performed a matched cohort study using data from three randomized controlled trials on abundant microaspiration in patients under mechanical ventilation. Each cirrhotic patient was matched with three to four controls for gender, age ± 5 years and simplified acute physiology score II (SAPS II) ± 5 points. Abundant microaspiration was defined by significant levels of pepsin and alpha-amylase in >30% of tracheal aspirates. All tracheal aspirates were collected for the first 48 h of the study period. The percentage of patients with abundant gastric-content microaspiration was the primary outcome. The abundant microaspiration of oropharyngeal secretions, VAP incidence, the duration of mechanical ventilation, length of intensive care unit (ICU) stay and mortality were the secondary outcomes. A. total of 39 cirrhotic patients were matched to 138 controls. The percentage of patients with abundant gastric-content microaspiration did not differ between the two groups (relative risk: 0.91 (95% CI: 0.75 to 1.10)). There was no significant difference between the two groups in terms of the abundant microaspiration of oropharyngeal secretions, VAP, the duration of mechanical ventilation, the length of ICU stay and mortality. Our results suggest that cirrhosis is not associated with abundant gastric-content microaspiration.
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Kulkarni AV, Premkumar M, Arab JP, Kumar K, Sharma M, Reddy ND, Padaki NR, Reddy RK. Early Diagnosis and Prevention of Infections in Cirrhosis. Semin Liver Dis 2022; 42:293-312. [PMID: 35672014 DOI: 10.1055/a-1869-7607] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Strategies to prevent infection and improve outcomes in patients with cirrhosis. HAV, hepatitis A virus; HBV, hepatitis B virus; COVID-19, novel coronavirus disease 2019; NSBB, nonselective β-blocker; PPI, proton pump inhibitors.Cirrhosis is a risk factor for infections. Majority of hospital admissions in patients with cirrhosis are due to infections. Sepsis is an immunological response to an infectious process that leads to end-organ dysfunction and death. Preventing infections may avoid the downstream complications, and early diagnosis of infections may improve the outcomes. In this review, we discuss the pathogenesis, diagnosis, and biomarkers of infection; the incremental preventive strategies for infections and sepsi; and the consequent organ failures in cirrhosis. Strategies for primary prevention include reducing gut translocation by selective intestinal decontamination, avoiding unnecessary proton pump inhibitors' use, appropriate use of β-blockers, and vaccinations for viral diseases including novel coronavirus disease 2019. Secondary prevention includes early diagnosis and a timely and judicious use of antibiotics to prevent organ dysfunction. Organ failure support constitutes tertiary intervention in cirrhosis. In conclusion, infections in cirrhosis are potentially preventable with appropriate care strategies to then enable improved outcomes.
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Affiliation(s)
- Anand V Kulkarni
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Madhumita Premkumar
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Juan P Arab
- Departamento de Gastroenterologia, Escuela de Medicina, Pontificia Universidad Catolica de Chile, Santiago, Chile
| | - Karan Kumar
- Department of Hepatology, Mahatma Gandhi Medical College and Hospital, Jaipur, Rajasthan, India
| | - Mithun Sharma
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nageshwar D Reddy
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Nagaraja R Padaki
- Department of Hepatology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India
| | - Rajender K Reddy
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
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White K, Tabah A, Ramanan M, Shekar K, Edwards F, Laupland KB. 90-day Case-Fatality in Critically ill Patients with Chronic Liver Disease Influenced by Presence of Portal Hypertension, Results from a Multicentre Retrospective Cohort Study. J Intensive Care Med 2022; 38:5-10. [PMID: 35892180 DOI: 10.1177/08850666221100408] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND Critical illness in patients with chronic liver disease (CLD) is increasing in occurrence, and by virtue of its adverse effect on prognosis, its presence may influence the decision to offer admission to intensive care units (ICU). Our objective was to examine the determinants and outcome of patients with CLD admitted to ICU. METHODS A retrospective cohort of patients admitted to four adult ICUs in Queensland, Australia from 2017 to 2019. Patients with mild or moderate-severe CLD were defined by the absence and presence of portal hypertension, respectively, and were was determined using granular ICU and state-wide administrative databases. The primary outcome was 90-day all cause case-fatality. RESULTS We included 3836 patients in the analysis, of which, 60 (2%) had mild liver disease and 132 (3%) had moderate-severe liver disease . Patients with CLD had higher incidence of other co-morbidities with the median adjusted-Charlson co-morbidity index (CCI) was 1 (interquartile range; IQR 0-3) for no CLD, 2 (IQR 1.5-4) for mild CLD, and 3 (IQR 2-5) for moderate-severe CLD. Case-fatality rates at 90 days was 17% for no CLD, 25% for mild CLD, and 41% for moderate-severe CLD. Among those with mild and moderate-severe CLD, an increased co-morbidity burden as measured by an adjusted CCI score of low (0-3), medium (4-5), high (6-7) and very high (>7) resulted in increasing case-fatality rates of 24-40%, 11-28.5%, 33-62%, and 50% respectively. Moderate-severe CLD, but not mild CLD, was independently associated with increased case-fatality at 90 days (Odds Ratio 1.58; 95% confidence interval 1.01-2.48; p = 0.004) after adjusting for medical co-morbidities and severity of illness using logistic regression analysis. CONCLUSIONS Although patients with moderate-severe CLD have an increased risk for 90-day case-fatality, patients with mild CLD are not at higher risk for death following ICU admission.
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Affiliation(s)
- Kyle White
- Intensive Care Unit, 1966Princess Alexandra Hospital, Woolloongabba, Queensland, Australia.,Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia
| | - Alexis Tabah
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, 60077Redcliffe Hospital, Redcliffe, Queensland, Australia
| | - Mahesh Ramanan
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, 60075Caboolture Hospital, Caboolture, Queensland, Australia
| | - Kiran Shekar
- Faculty of Medicine, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Unit, The Prince Charles Hospital, Brisbane, Queensland, Australia
| | - Felicity Edwards
- 1969Queensland University of Technology (QUT), Brisbane, Queensland, Australia
| | - Kevin B Laupland
- 1969Queensland University of Technology (QUT), Brisbane, Queensland, Australia.,550021Department of Intensive Care Services, Royal Brisbane and Women's Hospital, Brisbane, Queensland, Australia
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Chen GH, Wu RL, Huang F, Wang GB, Zheng MJ, Yu XJ, Wang W, Hou LJ, Ye ZH, Zhang XH, Zhao HC. Liver Transplantation in Acute-on-Chronic Liver Failure: Excellent Outcome and Difficult Posttransplant Course. Front Surg 2022; 9:914611. [PMID: 35860200 PMCID: PMC9289224 DOI: 10.3389/fsurg.2022.914611] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2022] [Accepted: 06/13/2022] [Indexed: 11/13/2022] Open
Abstract
Background Acute-on-chronic liver failure (ACLF) patients have high mortality in a short period of time. This study aimed to compare the prognosis of transplanted ACLF patients to that of nontransplanted ACLF patients and decompensated cirrhosis recipients. Methods Clinical data of 29 transplanted ACLF patients, 312 nontransplanted ACLF patients, and 60 transplanted decompensated cirrhosis patients were retrospectively collected. Propensity score matching (PSM) analysis was used to match patients between different groups. Results After PSM, the 90-day and 1-year survival of transplanted ACLF patients was significantly longer than that of nontransplant controls. Although the 90-day survival and 1-year survival of ACLF recipients was similar to that of decompensated cirrhosis controls, ACLF recipients were found to have longer mechanical ventilation, longer intensive care unit (ICU) stay, longer hospital stay, higher incidence of tracheotomy, higher expense, and higher morbidity of complication than matched decompensated cirrhosis controls. The 90-day and 1-year survival of transplanted ACLF grade 2–3 patients was also significantly longer than that of nontransplanted controls. Conclusions Liver transplantation can strongly improve the prognosis of ACLF patients. Despite having more burdens (including longer mechanical ventilation, longer ICU stay, higher incidence of tracheotomy, longer hospital stay, higher hospitalization expense, and higher complication morbidity), ACLF recipients can obtain similar short-term and long-term survival to decompensated cirrhosis recipients. For severe ACLF patients, liver transplantation can also significantly improve their short-term and long-term survival.
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Affiliation(s)
- Guang-Hou Chen
- Organ Transplantation Center, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Ruo-Lin Wu
- Organ Transplantation Center, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Fan Huang
- Organ Transplantation Center, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Guo-Bin Wang
- Organ Transplantation Center, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Mei-Juan Zheng
- Department of Clinical Laboratory, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xiao-Jun Yu
- Organ Transplantation Center, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Wei Wang
- Organ Transplantation Center, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Liu-Jin Hou
- Organ Transplantation Center, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Zheng-Hui Ye
- Organ Transplantation Center, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Xing-Hua Zhang
- Organ Transplantation Center, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hong-Chuan Zhao
- Organ Transplantation Center, Department of General Surgery, The First Affiliated Hospital of Anhui Medical University, Hefei, China
- Correspondence: Hong-Chuan Zhao
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Baig SH, Vaid U, Yoo EJ. The Impact of Chronic Medical Conditions on Mortality in Acute Respiratory Distress Syndrome. J Intensive Care Med 2022; 38:78-85. [PMID: 35722731 DOI: 10.1177/08850666221108079] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
PURPOSE To examine the impact of chronic comorbidities on mortality in Acute Respiratory Distress Syndrome (ARDS). MATERIALS AND METHODS Retrospective cohort study of adults with ARDS (ICD-10-CM code J80) from the National Inpatient Sample between January, 2016 and December, 2018. For the primary outcome of mortality, we conducted weighted logistic regression adjusting for factors identified on univariate analysis as potentially significant or differing between the two groups at baseline. We used negative binomial regression adjusting for the same comorbidities to identify risk factors for longer length of stay (LOS) among ARDS survivors. RESULTS After exclusions, 1046 records were analyzed (3355 ARDS survivors and 1875 non-survivors.) The comorbidities examined included hypertension, diabetes mellitus, obesity, hypothyroidism, alcohol and drug use, chronic kidney disease (CKD), cardiovascular disease, chronic liver disease, chronic pulmonary disease and malignancy. In multivariate analysis, we found that malignancy (OR 2.26, 95% CI 1.84-2.78, p < 0.001), cardiovascular disease (OR 1.54, 95% CI 1.23-1.92, p < 0.001), and CKD (OR 1.75, 95% CI 1.22-2.50, p = 0.002) increased the risk of death. In interaction analyses, cardiovascular disease combined with either malignancy or CKD conferred higher odds of death compared to either risk factor alone. CONCLUSIONS The comorbidity of malignancy confers the most reliable risk of poor outcomes in ARDS with higher odds of hospital death and a simultaneous association with longer hospital LOS among survivors.
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Affiliation(s)
- Saqib H Baig
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, 12313Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Urvashi Vaid
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, 12313Thomas Jefferson University, Philadelphia, PA 19107, USA
| | - Erika J Yoo
- Division of Pulmonary, Allergy and Critical Care Medicine, Jane and Leonard Korman Respiratory Institute, 12313Thomas Jefferson University, Philadelphia, PA 19107, USA
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36
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Silva PL, Ball L, Rocco PRM, Pelosi P. Physiological and Pathophysiological Consequences of Mechanical Ventilation. Semin Respir Crit Care Med 2022; 43:321-334. [PMID: 35439832 DOI: 10.1055/s-0042-1744447] [Citation(s) in RCA: 29] [Impact Index Per Article: 9.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Mechanical ventilation is a life-support system used to ensure blood gas exchange and to assist the respiratory muscles in ventilating the lung during the acute phase of lung disease or following surgery. Positive-pressure mechanical ventilation differs considerably from normal physiologic breathing. This may lead to several negative physiological consequences, both on the lungs and on peripheral organs. First, hemodynamic changes can affect cardiovascular performance, cerebral perfusion pressure (CPP), and drainage of renal veins. Second, the negative effect of mechanical ventilation (compression stress) on the alveolar-capillary membrane and extracellular matrix may cause local and systemic inflammation, promoting lung and peripheral-organ injury. Third, intra-abdominal hypertension may further impair lung and peripheral-organ function during controlled and assisted ventilation. Mechanical ventilation should be optimized and personalized in each patient according to individual clinical needs. Multiple parameters must be adjusted appropriately to minimize ventilator-induced lung injury (VILI), including: inspiratory stress (the respiratory system inspiratory plateau pressure); dynamic strain (the ratio between tidal volume and the end-expiratory lung volume, or inspiratory capacity); static strain (the end-expiratory lung volume determined by positive end-expiratory pressure [PEEP]); driving pressure (the difference between the respiratory system inspiratory plateau pressure and PEEP); and mechanical power (the amount of mechanical energy imparted as a function of respiratory rate). More recently, patient self-inflicted lung injury (P-SILI) has been proposed as a potential mechanism promoting VILI. In the present chapter, we will discuss the physiological and pathophysiological consequences of mechanical ventilation and how to personalize mechanical ventilation parameters.
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Affiliation(s)
- Pedro Leme Silva
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Institute of Biophysics Carlos Chagas Filho, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy.,Department of Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
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37
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Prognostic Role of MELD-Lactate in Cirrhotic Patients' Short- and Long-Term Prognosis, Stratified by Causes of Cirrhosis. Can J Gastroenterol Hepatol 2022; 2022:8449579. [PMID: 35392026 PMCID: PMC8983169 DOI: 10.1155/2022/8449579] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2021] [Revised: 03/06/2022] [Accepted: 03/07/2022] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVES Recently, model for end-stage liver disease-lactate (MELD-LA) proved to be a superior predicting factor of inpatient mortality in patients with chronic liver disease. The study's objective was to evaluate the ability of MELD-LA to predict both short- and long-term mortality in critically ill cirrhotic patients stratified by causes of cirrhosis. MATERIALS AND METHODS This was a retrospective observational research of 469 cirrhotic patients entering intensive care unit. Clinical parameters and prognostic scores were measured and collected in the first 24 hours after entering intensive care unit. Follow-up duration was at least 5 years. Independent relationship between MELD-LA and mortality was evaluated by multivariate logistic regression analyses. Discrimination of scoring system was evaluated by the area under the receiver operating characteristic curve. Calibration of the score was evaluated by Hosmer-Lemeshow goodness of fit test for significance. RESULTS The MELD-LA score (odds ratio: 1.179, 95% confidence interval: 1.112-1.250, P < 0.001) was an independent risk factor for 15-day mortality. The area under the curve of MELD-LA was the highest (0.808, 95% confidence interval: 0.765-0.852) in predicting 15-day mortality and it had superior calibration. We found MELD-LA showed the best discrimination ability in cirrhotic patients caused by both alcohol and hepatitis (0.783, 95% confidence interval: 0.651-0.915) or alcohol alone (0.805, 95% confidence interval: 0.743-0.867). CONCLUSIONS MELD-LA performs better for predicting short-term prognosis in critically ill cirrhotic patients, especially caused by both alcohol and hepatitis or alcohol alone.
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38
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Kamran M, Khalid AB, Siddiqui HAB, Aftab A, Azmat R. Predictors of Outcome of Cirrhotic Patients Requiring Invasive Mechanical Ventilation: Experience From a Non-Transplant Tertiary Care Hospital in Pakistan. Cureus 2022; 14:e21517. [PMID: 35223293 PMCID: PMC8862690 DOI: 10.7759/cureus.21517] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/23/2022] [Indexed: 11/23/2022] Open
Abstract
Background Patients with known liver cirrhosis, irrespective of the etiology, have poor outcomes when put on invasive mechanical ventilation in an intensive care unit (ICU) setting. The clinical situation becomes even more complicated when such patients are managed in a non-transplant center. Various factors are associated with poor outcomes, and hence, various scoring systems are available to help determine the prognosis in patients with liver cirrhosis. These scoring systems are broadly classified into two categories, namely, ICU-specific scoring systems and liver disease-specific scoring systems. There is a dearth of data from Pakistan regarding which score better determines the prognosis of patients with liver cirrhosis admitted to the ICU. In this study, we aimed to determine the outcome of cirrhotic patients requiring invasive mechanical ventilation in a non-transplant tertiary care hospital in Pakistan using ICU-specific and liver disease-specific scoring systems. Methodology A retrospective study design was applied to a record of 88 cirrhotic patients admitted to the medical ICU of a tertiary care teaching hospital in Karachi, Pakistan, from January 2016 to November 2016. Patients with acute hepatitis were excluded. Data on patients’ characteristics, the reason for intubation, hepatic encephalopathy, the need for vasopressor support, and the duration of ICU and hospital stay were collected. Moreover, the first-day Acute Physiology and Chronic Health Evaluation (APACHE) II, Sequential Organ Failure Assessment (SOFA), Child-Turcotte-Pugh (CTP), and Model for End-Stage Liver Disease (MELD) scores were calculated, with mortality being the primary outcome measure. Results The most common etiology was hepatitis C (52.3%, 46/88). The most common reason for intubation was airway protection (57.9%, 51/88). Overall mortality was 71.6% (63/88). On univariate analysis, CTP score >10, MELD score >18, hepatic encephalopathy, bilirubin, prothrombin time, presence of tense ascites, and APACHE II were significantly associated with mortality. On multivariate analysis, CTP score >10 (odd ratio = 21; 95% confidence interval (CI): 4-104; p < 0.001) was an independent predictor of mortality. Area under curve was 0.89 (95% CI = 0.82-0.96) for CTP, 0.86 (95% CI = 0.77-0.95) for MELD, 0.81 (95% CI = 0.69-0.92) for APACHE II, and 0.81 (95% CI = 0.71-0.91) for SOFA in predicting mortality. Conclusions CTP and MELD scores are better predictors of short-term mortality in patients with liver cirrhosis requiring invasive mechanical ventilation compared to APACHE II and SOFA scores. CTP score >10 was an independent predictor of mortality.
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da Silveira F, Soares PHR, Marchesan LQ, da Fonseca RSA, Nedel WL. Assessing the prognosis of cirrhotic patients in the intensive care unit: What we know and what we need to know better. World J Hepatol 2021; 13:1341-1350. [PMID: 34786170 PMCID: PMC8568574 DOI: 10.4254/wjh.v13.i10.1341] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/25/2021] [Revised: 05/11/2021] [Accepted: 09/27/2021] [Indexed: 02/06/2023] Open
Abstract
Critically ill cirrhotic patients have high in-hospital mortality and utilize significant health care resources as a consequence of the need for multiorgan support. Despite this fact, their mortality has decreased in recent decades due to improved care of critically ill patients. Acute-on-chronic liver failure (ACLF), sepsis and elevated hepatic scores are associated with increased mortality in this population, especially among those not eligible for liver transplantation. No score is superior to another in the prognostic assessment of these patients, and both liver-specific and intensive care unit-specific scores have satisfactory predictive accuracy. The sequential assessment of the scores, especially the Sequential Organ Failure Assessment (SOFA) and Chronic Liver Failure Consortium (CLIF)-SOFA scores, may be useful as an auxiliary tool in the decision-making process regarding the benefits of maintaining supportive therapies in this population. A CLIF-ACLF > 70 at admission or at day 3 was associated with a poor prognosis, as well as SOFA score > 19 at baseline or increasing SOFA score > 72. Additional studies addressing the prognostic assessment of these patients are necessary.
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Affiliation(s)
- Fernando da Silveira
- Programa de Pós-Graduação em Pneumologia, Universidade Federal do Rio Grande do Sul, Porto Alegre 91430835, Brazil
- Intensive Care Unit, Grupo Hospitalar Conceição, Porto Alegre 91430835, Brazil
| | - Pedro H R Soares
- Intensive Care Unit, Grupo Hospitalar Conceição, Porto Alegre 91430835, Brazil
- Programa de Pós-Graduação em Neurociências, Universidade Federal do Rio Grande do Sul, Porto Alegre 91430835, Brazil
| | - Luana Q Marchesan
- Intensive Care Unit, Grupo Hospitalar Conceição, Porto Alegre 91430835, Brazil
- Programa de Pós-Graduação em Ciências da Saúde, Universidade Federal de Santa Maria, Santa Maria 97105900, Brazil
| | | | - Wagner L Nedel
- Intensive Care Unit, Grupo Hospitalar Conceição, Porto Alegre 91430835, Brazil
- Programa de Pós-Graduação em Bioquímica, Universidade Federal do Rio Grande do Sul, Porto Alegre 91430835, Brazil.
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40
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Fischer P, Stefanescu H, Hategan R, Procopet B, Ionescu D. Bacterial infection-related acute-on-chronic liver failure: The standpoint matters! J Hepatol 2021; 75:1009-1010. [PMID: 33984414 DOI: 10.1016/j.jhep.2021.04.046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2021] [Revised: 04/26/2021] [Accepted: 04/27/2021] [Indexed: 12/14/2022]
Affiliation(s)
- Petra Fischer
- University of Medicine and Pharmacy "Iuliu Hatieganu," 3rd Medical Clinic, Hepatology Department, Cluj-Napoca, Romania; Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor," Hepatology Department, Cluj-Napoca, Romania
| | - Horia Stefanescu
- Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor," Hepatology Department, Cluj-Napoca, Romania
| | - Raluca Hategan
- Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor," Anesthesia and Intensive Care Department, Cluj-Napoca, Romania
| | - Bogdan Procopet
- University of Medicine and Pharmacy "Iuliu Hatieganu," 3rd Medical Clinic, Hepatology Department, Cluj-Napoca, Romania; Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor," Hepatology Department, Cluj-Napoca, Romania.
| | - Daniela Ionescu
- Regional Institute of Gastroenterology and Hepatology "Prof. Dr. Octavian Fodor," Anesthesia and Intensive Care Department, Cluj-Napoca, Romania; University of Medicine and Pharmacy "Iuliu Hatieganu," Department of Anesthesia and Intensive Care I, Cluj-Napoca, Romania
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41
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[Clinical presentation of bleeding in critically ill patients in the intensive care unit : Organ systems and clinical implications]. Med Klin Intensivmed Notfmed 2021; 116:482-490. [PMID: 34427697 DOI: 10.1007/s00063-021-00845-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2021] [Accepted: 07/09/2021] [Indexed: 10/20/2022]
Abstract
Bleedings are frequent and clinically important complications in critically ill patients in the intensive care unit, and-depending on location and intensity-are associated with high morbidity and mortality. The clinical impact of different bleeding entities is affected by the location (e.g. intracerebral bleedings), the severity (e.g. fulminant variceal bleeding) and the incidence (e.g. gastrointestinal bleeding) of the respective bleeding type. Therapy varies among bleeding entities, but consists of stabilization of the patient, control of the bleeding, and prevention of complications. This review describes relevant therapeutic aspects of selected bleeding complications in critically ill patients.
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42
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Jeon YH, Kim IY, Jang GS, Song SH, Seong EY, Lee DW, Lee SB, Kim HJ. Clinical outcomes and prognostic factors of mortality in liver cirrhosis patients on continuous renal replacement therapy in two tertiary hospitals in Korea. Kidney Res Clin Pract 2021; 40:687-697. [PMID: 34510860 PMCID: PMC8685364 DOI: 10.23876/j.krcp.21.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/06/2021] [Accepted: 05/29/2021] [Indexed: 11/04/2022] Open
Abstract
Background Data on liver cirrhosis (LC) patients undergoing continuous renal replacement therapy (CRRT) are lacking despite of the dismal prognosis. We therefore evaluated clinical characteristics and predictive factors related to mortality in LC patients undergoing CRRT. Methods We performed a retrospective observational study at two tertiary hospitals in Korea. A total of 229 LC patients who underwent CRRT were analyzed. Patients were classified into survivor and non-survivor groups. We used multivariable Cox regression analyses to identify predictive factors of in-hospital mortality. Results During a median follow-up of 5 days (interquartile range, 1-19 days), in-hospital mortality rate was 66.4%. In multivariable analysis, the Acute Physiology and Chronic Health Evaluation II (APACHE II) score (hazard ratio [HR], 1.03; 95% confidence interval [CI], 1.01-1.06; p = 0.02), Model for End-Stage Liver Disease (MELD) score (HR, 1.08; 95% CI, 1.04-1.11; p > 0.001), and delivered CRRT dose (HR, 0.95; 95% CI, 0.92-0.98; p = 0.002) were significant risk factors for in-hospital mortality. Patients with a CRRT delivered dose < 25 mL/kg/hr had a higher mortality rate than those with a delivered dose > 35 mL/kg/hr (HR, 3.13; 95% CI, 1.62-6.05; p = 0.001). Subgroup analysis revealed that a CRRT delivered dose > 25 mL/kg/hr was a significant risk factor for in-hospital mortality among LC patients with a MELD score ≥ 30. Conclusion High APACHE II score, high MELD score, and low delivered CRRT dose were significant risk factors for in-hospital mortality. CRRT delivered dose impacted mortality significantly, especially in patients with a MELD score ≥ 30.
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Affiliation(s)
- You Hyun Jeon
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Il Young Kim
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Gum Sook Jang
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea
| | - Sang Heon Song
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Eun Young Seong
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
| | - Dong Won Lee
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Soo Bong Lee
- Department of Internal Medicine, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea.,Research Institute for Convergence of Biomedical Science and Technology, Pusan National University Yangsan Hospital, Yangsan, Republic of Korea
| | - Hyo Jin Kim
- Department of Internal Medicine, Pusan National University Hospital, Busan, Republic of Korea.,Biomedical Research Institute, Pusan National University Hospital, Busan, Republic of Korea
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Durand F, Roux O, Weiss E, Francoz C. Acute-on-chronic liver failure: Where do we stand? Liver Int 2021; 41 Suppl 1:128-136. [PMID: 34155793 DOI: 10.1111/liv.14855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 12/12/2022]
Abstract
Acute-on-chronic liver failure (ACLF) is defined by the rapid development of organ(s) failure(s) associated with high rates of early (28-day) mortality in patients with cirrhosis. ACLF has been categorized into three grades of increasing severity according to the nature and number of organ failures. In patients with grade 3 ACLF, 28-day mortality is >70%. While the definition of ACLF has been endorsed by European scientific societies, North American and Asian Pacific associations have proposed alternative definitions. A prognostic score called the CLIF-C ACLF score provides a more precise assessment of the prognosis of patients with ACLF. Although bacterial infections and variceal bleeding are common precipitating factors, no precipitating factor can be identified in almost 60% of patients with ACLF. There is increasing evidence that cirrhosis is a condition characterized by a systemic inflammatory state and occult infections or translocation of bacteria or bacterial products from the lumen of the GUT to the systemic circulation which could play a role in the development of ACLF. Simple and readily available variables to predict the occurrence of ACLF in patients with cirrhosis have been identified and high-risk patients need careful management. Whether prolonged administration of statins, rifaximin or albumin can prevent ACLF requires further study. Patients with organ(s) failure(s) may needed to be admitted to the ICU and there should be no hesitation in admitting patients with cirrhosis to the ICU. No benefit to survival was observed with albumin dialysis and rescue transplantation is the best option in the most severe patients. One-year post-transplant survival rates exceeding 70%-75% have been reported, including in patients with grade 3 ACLF but these patients were highly selected. Criteria have been proposed to define futile transplantation (too ill to be transplanted), but these criteria need to be refined to include age, comorbidities and frailty in addition to markers of disease severity.
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Affiliation(s)
- François Durand
- Hepatology & Liver Intensive Care Hospital Beaujon, Clichy, France.,INSERM U1149, Clichy, France.,University of Paris, Clichy, France
| | - Olivier Roux
- Hepatology & Liver Intensive Care Hospital Beaujon, Clichy, France
| | - Emmanuel Weiss
- INSERM U1149, Clichy, France.,Anesthesiology and Intensive Care, Clichy, France
| | - Claire Francoz
- Hepatology & Liver Intensive Care Hospital Beaujon, Clichy, France.,INSERM U1149, Clichy, France
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Ying S, Li X. Renal and brain failure predict mortality of patients with acute-on-chronic liver failure admitted to the intensive care unit. Ann Hepatol 2021; 21:100296. [PMID: 33346095 DOI: 10.1016/j.aohep.2020.100296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/03/2020] [Accepted: 11/23/2020] [Indexed: 02/04/2023]
Affiliation(s)
- Shishi Ying
- Emergecy Department, YiWu Central Hospital, Zhejiang 322000, China
| | - Xiaofei Li
- Department of Infectious Diseases, YiWu Central Hospital, Zhejiang 322000, China.
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Incidence and management patterns of alcohol-related liver disease in Korea: a nationwide standard cohort study. Sci Rep 2021; 11:6648. [PMID: 33758281 PMCID: PMC7987970 DOI: 10.1038/s41598-021-86197-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Accepted: 03/09/2021] [Indexed: 12/19/2022] Open
Abstract
The recent incidence and management patterns of alcohol-related liver disease (ARLD) are not well defined in Korea. We sought to evaluate the epidemiology of ARLD with regard to disease severity and alcohol cessation management after diagnosis. We performed an observational cohort study of standardized Common Data Model data from the Health Insurance Review and Assessment-National Patient Samples database between 2012 and 2016. The incidence and demographic properties of ARLD were extracted and divided into non-cirrhotic alcoholic liver disease (ALD) and alcoholic liver cirrhosis (ALC). ALC was compared with non-alcoholic cirrhosis by severity at diagnosis. The management patterns were captured by the initiation of pharmaco- and behavioral therapy for alcohol cessation. We analyzed data from 72,556 ALD to 7295 ALC patients. The ALD incidence was stable from 990 to 1025 per 100,000 people. In ALD, the proportion of patients who were ≥ 65 years old, the proportion of female patients, and the comorbidity index increased significantly during the study period (all P values < 0.001). ALC accounted for > 20% of all cirrhosis, with decompensation occurring twice as often as in non-alcoholic cirrhosis. The initiation of alcoholism management was stationary in ARLD, remaining at < 10% for both pharmacotherapy and behavioral therapy, regardless of severity or the site of diagnosis. The incidence of ARLD did not decrease during the study period. Moreover, an increasing trend in the proportion of people vulnerable to drinking was observed. Unfortunately, management for the cessation of alcohol use remains very low. The best way to manage ARLD should be evaluated in further study.
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Kubesch A, Peiffer KH, Abramowski H, Dultz G, Graf C, Filmann N, Zeuzem S, Bojunga J, Friedrich-Rust M. The presence of liver cirrhosis is a strong negative predictor of survival for patients admitted to the intensive care unit - Cirrhosis in intensive care patients. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2021; 59:657-664. [PMID: 33728617 DOI: 10.1055/a-1401-2387] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
BACKGROUND AND AIMS Liver cirrhosis is a systemic disease that substantially impacts the body's physiology, especially in advanced stages. Accordingly, the outcome of patients with cirrhosis requiring intensive care treatment is poor. We aimed to analyze the impact of cirrhosis on mortality of intensive care unit (ICU) patients compared to other frequent chronic diseases and conditions. METHODS In this retrospective study, patients admitted over three years to the ICU of the Department of Medicine of the University Hospital Frankfurt were included. Patients were matched for age, gender, pre-existing conditions, simplified acute physiology score (SAPS II), and therapeutic intervention scoring system (TISS). RESULTS A total of 567 patients admitted to the ICU were included in the study; 99 (17.5 %) patients had liver cirrhosis. A total of 129 patients were included in the matched cohort for the sensitivity analysis. In-hospital mortality was higher in cirrhotic patients than non-cirrhotic patients (p < 0.0001) in the entire and matched cohort. Liver cirrhosis remained one of the strongest independent predictors of in-hospital mortality (entire cohort p = 0.001; matched cohort p = 0.03) along with dialysis and need for transfusion in the multivariate logistic regression analysis. Furthermore, in the cirrhotic group, the need for kidney replacement therapy (p < 0.001) and blood transfusion (p < 0.001) was significantly higher than in the non-cirrhotic group. CONCLUSIONS: In the presented study, liver cirrhosis was one of the strongest predictors of in-hospital mortality in patients needing intensive care treatment along with dialysis and the need for ventilation. Therefore, concerted efforts are needed to improve cirrhotic patients' outcomes, prevent disease progression, and avoid complications with the need for ICU treatment in the early stages of the disease.
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Affiliation(s)
- Alica Kubesch
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt
| | | | - Hannes Abramowski
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt.,Department of Anaesthesiology, Intensive Care Medicine and Pain Therapy, Goethe-University Hospital Frankfurt
| | - Georg Dultz
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt
| | - Christina Graf
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Goethe-University Frankfurt
| | - Stefan Zeuzem
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt
| | - Jörg Bojunga
- Department of Internal Medicine 1, Goethe-University Hospital Frankfurt
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Samuel D. Systemic inflammation and liver cirrhosis complications: Driving or secondary event? How to square the circle? J Hepatol 2021; 74:508-510. [PMID: 33478857 DOI: 10.1016/j.jhep.2021.01.001] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/03/2021] [Accepted: 01/04/2021] [Indexed: 12/16/2022]
Affiliation(s)
- Didier Samuel
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Villejuif, F-94800, France; Univ Paris-Saclay, UMR-S 1193, Université Paris-Saclay, Villejuif, F-94800, France; Inserm, Unité 1193, Université Paris-Saclay, Villejuif, F-94800, France; Hepatinov, Villejuif, F-94800, France.
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48
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Lactate and Bilirubin Index: A New Indicator to Predict Critically Ill Cirrhotic Patients’ Prognosis. Can J Gastroenterol Hepatol 2021. [DOI: 10.1155/2021/6624177] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022] Open
Abstract
Objectives. We aimed to perform external validation of the prognostic value of the lactate and bilirubin (LB) index, a new indicator, and compare the ability of the LB index and other scoring systems to predict both short- and long-term mortality in critically ill cirrhotic patients. Materials and Methods. A number of 479 cirrhotic patients admitted into ICU were included in our research. We measured prognostic scores in the first 24 hours including LB index, Child–Pugh, SOFA, CLIF-SOFA, and MELD scores. The LB index was calculated as follows: ln [1000 × lactate (mmol/L) × bilirubin (µmol/L)]/2. The primary outcomes were 28-day and 3-year all-cause mortality. Multivariate logistic regression analyses were used to investigate the independent association between the LB index and the mortality in critically ill cirrhotic patients. The area under the receiver operating characteristic curve was used to assess the prediction accuracy of short- and long-term mortality of the clinical score. Calibration of the score was evaluated by Hosmer–Lemeshow goodness-of-fit test for significance. Results. Multivariate logistic regression analysis identified that the LB index (odds ratio: 5.487, 95% confidence interval: 3.542–8.501,
) was the strongest predictor for 28-day mortality. The LB index gave the highest area under the curve (0.791, 95% confidence interval: 0.747–0.836) in predicting 28-day mortality. For predicting 3-year mortality, the model for end-stage liver disease (MELD) score showed better discrimination ability with an area under the curve of 0.726 (95% confidence interval: 0.680–0.771). The risk of mortality significantly increased when the clinical scores were ≥ the optimal cutoff values. Conclusions. The LB index, a simple prognostic indicator, performs well in predicting critically ill cirrhotic patients’ short-term prognosis, while, for long-term prognosis, the MELD score is more appropriate.
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Cheung K, Mailman JF, Crawford JJ, Karvellas CJ, Sy E. Trends and outcomes of mechanically ventilated cirrhotic patients in the United States from 2005–2014. J Intensive Care Soc 2021; 23:139-149. [DOI: 10.1177/1751143720985293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
Purpose Cirrhotic patients in organ failure are frequently admitted to intensive care units (ICUs) to receive invasive mechanical ventilation (IMV). We evaluated the trends of hospitalizations, in-hospital mortality, hospital costs, and hospital length of stay (LOS) of IMV patients with cirrhosis. Methods We analyzed the United States National Inpatient Sample from 2005–2014. We selected discharges of IMV adult (≥18 years) patients with cirrhosis using the International Classification of Diseases, 9th Edition , Clinical Modification codes. Trends were assessed using linear regression and joinpoint regression. Results Between 2005 and 2014, there were approximately 9,441,605 hospitalizations of IMV adult patients, of which 4.7% had cirrhosis. There was an increasing trend in the total number of IMV cirrhotic patient hospitalizations (annual percent change [APC] 7.0%, 95% confidence interval [CI] 6.4%; 7.6%, Ptrend < 0.001). The in-hospital case-fatality ratio declined between 2005–2011 (APC –2.9%, 95% CI, –3.4%; –2.4%, Ptrend < 0.001); however, it remained similar between 2011–2014 ( Ptrend = 0.58). The total annual hospital costs of all IMV cirrhotic patients increased from approximately $1.2 billion USD in 2005 to $2.7 billion USD in 2014 ( Ptrend < 0.001). The mean hospital costs per patient and mean LOS declined between 2005 and 2014 ( Ptrend < 0.001 and Ptrend = 0.01 respectively). Conclusions The total number of hospitalizations and total annual costs of IMV patients with cirrhosis have been increasing over time. However, past hesitancy around admitting cirrhotic patients to the ICU may need to be tempered by the improving mortality trends in this patient population.
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Affiliation(s)
- Kyle Cheung
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
| | - Jonathan F Mailman
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Department of Critical Care, Regina General Hospital, Regina, Saskatchewan, Canada
- Department of Pharmacy Services, Regina General Hospital, Regina, Saskatchewan, Canada
| | | | - Constantine J Karvellas
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
| | - Eric Sy
- University of Saskatchewan, Saskatoon, Saskatchewan, Canada
- Department of Critical Care, Regina General Hospital, Regina, Saskatchewan, Canada
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pCLIF-SOFA is a reliable outcome prognostication score of critically ill children with cirrhosis: an ESPNIC multicentre study. Ann Intensive Care 2020; 10:137. [PMID: 33052510 PMCID: PMC7560665 DOI: 10.1186/s13613-020-00753-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2020] [Accepted: 10/03/2020] [Indexed: 12/15/2022] Open
Abstract
Background and aims Data on outcome of critically ill children with cirrhosis are scarce. We aimed to evaluate the prognostic accuracy of sequential organs scoring systems in children with cirrhosis admitted to Paediatric Intensive Care Units (PICU). Methods We performed a multicentre retrospective analysis of children with cirrhosis admitted into four European PICUs between 2011 and 2016. Investigators were members of the ESPNIC liver failure and support working group. Paediatric End-Stage Liver Disease (PELD) and paediatric chronic liver failure sequential organ failure assessment score (pCLIF-SOFA) diagnostic accuracy for 28- and 60-day liver transplantation, 28-day mortality and 60-day composite outcome (ie. death or liver transplantation) were tested. Results One-hundred-and-thirty children were included. The main causes for PICU admission were acute-on-chronic liver failure (ACLF), gastrointestinal bleeding and sepsis. Twenty-nine percent died and 22.3% were transplanted by day-60 after PICU admission. On multivariable analysis, pCLIF-SOFA was the only predictor of mortality at day-28 and of composite outcome. Both pCLIF-SOFA and ACLF were independently associated with emergent liver transplantation. The pCLIF-SOFA score higher than 9 well predicted a 28-day mortality with a sensitivity of 87.8% and a specificity of 77.3%. A pCLIF-SOFA score higher than 7 was independently associated with liver transplantation on day-60. Stage 3 AKI assessed with KDIGO classification was significantly associated with 28-day mortality. Conclusions Half of critically ill cirrhotic children admitted to PICU either died or were transplanted within the initial 28-day period. On admission pCLIF-SOFA score accurately identify patients transplanted at day-28 and day-60 to those alive without LT and is associated with 28-day mortality and composite outcome at day-60.
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