The impact of organ dysfunction in cirrhosis: Survival at a cost?

Background & Aims

The incidence of cirrhosis and subsequent development of organ dysfunction (OD) requiring intensive care unit (ICU) support is rising. Historically, critically ill cirrhotics are perceived as having poor prognosis and substantial cost of care.

Methods

The aim was to prospectively analyse resource utilisation and cost of a large cohort of patients (n=660) admitted to a Liver ICU from 2000 to 2007 with cirrhosis and OD. Child Pugh, MELD, SOFA, APACHE II, and organ support requirements were collected. The Therapeutic Intervention Scoring System (TISS) score, a validated tool for estimating cost in ICU, was calculated daily. Logistic regression was used to determine independent predictors of increased cost.

Results

Alcohol was the most common etiology (47%) and variceal bleeding (VB) the most common reason for admission (35%). Invasive ventilatory support was required in 74% of cases, vasopressors in 49%, and 50% required renal replacement therapy. Forty-nine per cent of non-transplanted patients survived to ICU discharge. Median TISS score and ICU cost per patient were 261 and €14,139, respectively. VB patients had the highest survival rates (53% vs. 24%; p<0.001) and lower associated cost. A combination of VB (OR 0.48), need for ventilation (OR 2.81), low PO₂/FiO₂ on admission (OR 0.97), and lactate (OR 0.93) improved cost prediction on multivariate analysis (AUROC 0.7; p<0.001) but organ failure scores per se were poor predictors of cost.

Conclusions

Patients with cirrhosis and OD result in considerable resource expenditure but have acceptable hospital survival. Further health economic assessment and outcome prediction tools are required to appropriately target resource utilisation.

Abbreviations: APACHE, Acute Physiology and Chronic Health Evaluation, A-o-CLF, acute-on-chronic liver failure, CVVHF, continuous veno-venous hemofiltration, €, euro, GBP, Great Britain Pounds, GCS, Glasgow Coma Score, ICU, intensive care unit, LT, liver transplantation, MAP, mean for arterial blood pressure, MELD, model of end-stage liver disease, RRT, renal replacement therapy, SOFA, Sequential Organ Failure Assessment, SIRS, systemic inflammatory response syndrome, TISS, Therapeutic Intervention Scoring System

Keywords: Cirrhosis, Organ dysfunction, Acute-on-chronic liver failure, Intensive care, Cost, Outcome