BJA Advance Access originally published online on July 18, 2006
British Journal of Anaesthesia 2006 97(4):496-498; doi:10.1093/bja/ael177
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One year outcome of intensive care patients with decompensated alcoholic liver disease
Department of Anaesthesia, Critical Care and Pain Management, The Royal Infirmary of Edinburgh at Little France 51 Little France Crescent, Old Dalkeith Road, Edinburgh EH16 4SA, UK
*Corresponding author. E-mail: brian.cook{at}luht.scot.nhs.uk
Accepted for publication May 31, 2006.
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Abstract |
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Background. We aimed to examine the outcome of patients with decompensated alcoholic liver disease (ALD) admitted to a general intensive care unit (ICU).
Methods. Retrospective observational cohort study of intensive care admissions over a 3 yr period was conducted. The study was set in an ICU in a UK university hospital with a tertiary liver referral unit. One hundred and ten admissions, involving 107 patients, with decompensated ALD were included. Intensive care, hospital, and 6 and 12 months mortality were recorded along with the outcome in diagnostic and organ system support subgroups. Intensive care, hospital, 6 month and 12 month mortality rates were 58, 71, 78 and 81%.
Results. Hospital mortality in the sepsis/multiorgan failure group was 88%. Sixty-nine per cent of patients who were ventilated but required no other organ support survived to hospital discharge. However, the requirement for any other organ support, or a raised creatinine (>120 µmol litre–1) in the first 24 h, reduced the hospital survival to <15%. In those patients requiring acute renal replacement therapy, the hospital mortality was 94%.
Conclusion. Decompensated ALD requiring intensive care admission is associated with a high hospital mortality and consideration should be given to the futility of escalating organ support measures, particularly when renal replacement therapy is required.
Keywords: complications, alcohol liver disease; critical care, outcome; liver, failure
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Introduction |
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Alcohol-related deaths in the UK have increased in the past two decades.1 Most liver-related morbidity and mortality occurs in patients with cirrhosis who develop portal hypertension and hepatocellular dysfunction. The mortality rate is 10% per decade in all patients with alcohol-related cirrhosis, compared with 1 yr and 5 yr mortality rates exceeding 50 and 70%, respectively, in those with jaundice, ascites, encephalopathy and cachexia.2 Many patients with advanced alcoholic liver disease (ALD) are admitted to an intensive care unit (ICU) and, in addition to the clinical challenges they present, they utilize significant hospital resources.3 In 1982, Goldfarb described mortality rates exceeding 89% in patients with cirrhosis requiring intensive care.4 There have been no published studies focused on the outcome of patients with ALD admitted to intensive care in the UK.
We present a detailed retrospective observational cohort study of patients with decompensated ALD admitted to an ICU over a 3 yr period, with 1 yr postdischarge follow-up.
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Methods |
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The 1146 bed University Hospital contained a supraregional tertiary referral centre for hepatobiliary disease and the Scottish Liver Transplant Unit. It had a 12 bed medical and surgical ICU.
A retrospective survey was carried out of all patients admitted to the ICU with decompensated ALD over a 3 yr period between January 1, 1999 and December 31, 2001. The study was discussed with the chairman of the local Research and Ethics Committee. No formal Ethics Committee submission was deemed necessary for this retrospective survey. Information was obtained from the ICU computer database (WardWatcherTM) and the ICU admissions book. The admission diagnosis was verified by checking the ICU clinical records and discharge summaries. Follow-up information was obtained from the ICU database, and by contacting primary care physicians. Postoperative patients, including liver transplant recipients were excluded from the study. Information was obtained on patient characteristics, severity of illness (APACHE II) at 24 h, organ support, and ICU, hospital, 6 month and 12 month mortality. Patients with decompensated ALD were subgrouped based on the main presenting feature. These were gastrointestinal haemorrhage, sepsis/multiorgan failure (MOF) and encephalopathy. The encephalopathy group were patients who presented with decompensated ALD in the absence of demonstrable sepsis or gastrointestinal haemorrhage. The indications for mechanical ventilation, use and choice of vasoactive drugs, or commencement of renal replacement therapy were not studied. Those patients having renal replacement therapy had a detailed patient-note review by one of the authors.
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Results |
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A total of 107 patients with 110 admissions to ICU with decompensated ALD were studied. Patient characteristic information is shown in Table 1. One patient was readmitted to ICU during the same hospital admission. Two patients were admitted to ICU on separate hospital admissions. One patient with gastrointestinal haemorrhage was lost to follow-up. Three patients died in <4 h after admission and were excluded from APACHE II scoring in our database. One patient was admitted with a retroperitoneal bleed and died in ICU.
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ICU, hospital, 6 month and 12 month mortalities are listed in Table 2.
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Table 3 illustrates the reasons for admission to ICU, and the outcomes in these diagnostic subgroups. Thirty-seven patients received renal replacement therapy. However, one patient was on chronic dialysis, and another had renal replacement therapy despite having a good urine output and a peak creatinine of 277 µmol litre–1. The indication for renal replacement in this patient was not clear. Therefore, only two patients with commonly accepted indications for acute renal replacement therapy survived, resulting in a hospital mortality of 94% (33 out of 35). Sixty-nine per cent of patients who required only mechanical ventilation, survived to hospital discharge. However, the requirement for any other organ support, or presence of a raised creatinine >120 µmol litre–1 in the first 24 h, reduced the hospital survival to <15%. Table 4 summarizes the mortality rates in organ failure and support groups.
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Discussion |
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It is known that patients with liver cirrhosis admitted to intensive care who require organ support, have a poor prognosis. Overall mortality rates of 43–100% have been described.4–11 Comparisons between the studies are difficult as a result of multiple aetiologies of liver disease, different illness severities, and inclusion of surgical and liver transplant patients. Our observed ICU mortality rate of 58% is comparable with a previous study showing an overall mortality rate of 52% in patients with decompensated cirrhosis admitted to a medical ICU.11 The observed 12 month mortality was 81%, which compares with a 92% 12 month mortality in a heterogeneous group of 243 cirrhotic patients in ICU.12
Mechanical ventilation has been shown to be associated with ICU mortality rates of 83–95% in patients with cirrhosis.4 6 13 We observed a 60% ICU mortality in all ventilated patients, but only 4% in those who did not require additional support. Shock requiring support with vasoactive drugs is associated with a worse outcome in cirrhosis, and has been shown to be an independent predictor of mortality.5 8 The presence of septic shock has been associated with a 100% mortality.14 Seventy per cent of our patients required infusions of routine vasoactive agents, of whom 86% died in hospital. The intermittent use of other vasoactive drugs, e.g. Terlipressin, was not studied, but may have influenced the need for vasoactive infusions. Acute renal failure (ARF) is associated with a high mortality in intensive care patients with hepatic dysfunction.5 6 8 Cosentino and colleagues found chronic liver disease to be the only premorbid condition associated with increased risk of death in ICU patients with ARF.15 We observed a 55% prevalence of renal impairment, defined as serum creatinine >120 µmol litre–1, in the first 24 h. Eighty-seven per cent of these patients died in hospital. Only two patients who received acute renal replacement therapy when needed survived to hospital discharge. It is interesting to note that both patients presented with urinary sepsis and had a low vasopressor requirement. The observed better outcome in these patients would have been expected when urinary sepsis was treated early, with little requirement for vasopressor support.
Multiple organ failure and multiple therapeutic interventions have been shown to be associated with high mortality.5 6 9 In these studies, mortality rates ranged from 6% in those with no organ failure to 97% for those with three or more organ systems failed. We observed a 91% hospital mortality in those with three organs supported. A recent study concluded that severity of acute illness did not correlate with ICU outcome in ventilated cirrhotic patients, although this group had a lower mean APACHE II score.16
In presenting this retrospective study, we recognize the problems in interpreting the information. Although the overall numbers are small, when compared with other studies of similar patients, this represents a significant cohort. We did not analyse the decision making processes involved in deciding on the indications for mechanical ventilation, vasopressor support or renal replacement therapy, or when to withhold or withdraw support. These decisions were made by the treating physicians on the basis of clinical indications or futility. The retrospective nature of this study cannot provide a standardized approach, but we would contend that it represents standard acceptable practice in a British specialist liver ICU. As expected, we have confirmed that patients with decompensated ALD have a poor hospital and 12 month outcome based on APACHE II scoring. The caution of applying population-based scoring systems to individuals is understood.
This study does, however, provide valuable information on a subgroup of critically ill patients. Few centres in the UK would be expected to see such numbers of patients with decompensated ALD, and it is informative to know the results in a tertiary referral centre. Based on the results from this small retrospective study, and the limited data collected, we cannot recommend that patients with decompensated ALD be denied renal replacement therapy in the event of multiple organ failure. However, it is of practical use to ICU clinicians to be informed of the very low probability of altering a fatal outcome. A large, prospective, multicentre, randomized control trial might answer this question. However, it is unlikely that such a trial is feasible, based on the numbers required, and the multiple confounding variables in the management of these patients. Until then, clinicians must base their decisions on the limited information available.
In conclusion, this retrospective study of patients admitted to intensive care with decompensated ALD confirms high hospital and 12 month mortality. While single organ support with ventilation carries a relatively good survival outcome, multiple organ support, particularly with renal failure, may be futile. We hope that in the face of a dramatic increase in alcohol abuse in the UK, this informs clinicians' decision making and the allocation of intensive care resources to these patients.
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References |
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