Assessment of Prognosis of Cirrhosis

François Durand, M.D.; Dominique Valla, M.D.

Disclosures

Semin Liver Dis. 2008;28(1):110-122. 

In This Article

Prognosis in the Particular Setting of the Intensive Care Unit

In general, the prognosis of cirrhotic patients admitted to the intensive care unit (ICU) due to multiorgan failure is especially poor. Mortality rates in patients with failure of two or three organ systems are estimated to be ∼75% and 95%, respectively.[69] Mortality is much higher than that of noncirrhotic patients with multiorgan failure. As an example, mortality rate among noncirrhotic patients with failure of two or three organ systems in a context of severe sepsis is ∼26% and 34%, respectively.[70] Among other factors, the poor outcome of cirrhotic patients with multiorgan failure results from a rapid alteration of liver function, a limited capacity for liver regeneration, and the absence of efficient artificial liver support systems. Predicting the outcome in this context may help optimize resource utilization, as aggressive management is not justified in all patients. However, it must be kept in mind that on the other hand, not all patients admitted to the ICU have a fatal outcome. In particular, some patients may be efficiently bridged to “rescue” transplantation with aggressive management.

In the particular setting of ICU, it can be reasonably assumed that Child-Pugh and MELD score have significant limitations for predicting very short-term survival. The more general Acute Physiology and Chronic Health Evaluation (APACHE) II[71] and sequential organ failure assessment (SOFA) scores[72] have been extensively validated in ICU patients. SOFA score is a relatively complex score based on respiration, coagulation, liver function, cardiovascular status, neurological status, and renal function. In cirrhotic patients admitted to the ICU, the accuracy of SOFA score was shown to be superior to that of APACHE II and Child-Pugh score with a c statistic of 0.94.[69] Although the assessment of MELD score has been limited in this context, it seems that its prognostic value is lower than that of general ICU scores.[73]

Overall, general ICU scores seem to be superior to “liver-oriented” prognostic scores in this context. However, some variables which are not included in general ICU scores may have a significant impact for predicting survival and justifying resource utilization. In particular, whether multiorgan failure is the consequence of terminal illness alone or the consequence of one or more iatrogenic factors may weight heavily on the probability of recovery.

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