title: The impact of organ dysfunction in cirrhosis: survival at a cost?
abstract: OBJECTIVE
  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 PO(2)/FiO(2) 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.
authors.affiliation: Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK.
authors.forename: Debbie L
authors.initials: DL
authors.lastname: Shawcross
authors.affiliation: Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK.
authors.forename: Mark J
authors.initials: MJ
authors.lastname: Austin
authors.affiliation: Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK.
authors.forename: Robin Daniel
authors.initials: RD
authors.lastname: Abeles
authors.affiliation: Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK.
authors.forename: Mark J W
authors.initials: MJW
authors.lastname: McPhail
authors.affiliation: Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK.
authors.forename: Andrew D
authors.initials: AD
authors.lastname: Yeoman
authors.affiliation: Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK.
authors.forename: Nicholas J
authors.initials: NJ
authors.lastname: Taylor
authors.affiliation: Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK.
authors.forename: Andrew J
authors.initials: AJ
authors.lastname: Portal
authors.affiliation: Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK.
authors.forename: Khaleel
authors.initials: K
authors.lastname: Jamil
authors.affiliation: Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK.
authors.forename: Georg
authors.initials: G
authors.lastname: Auzinger
authors.affiliation: Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK.
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Sizer
authors.affiliation: Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK.
authors.forename: William
authors.initials: W
authors.lastname: Bernal
authors.affiliation: Liver Intensive Care Unit and Institute of Liver Studies and Transplantation, King's College London School of Medicine at King's College Hospital, Denmark Hill, London SE5 9RS, UK. Electronic address: julia.wendon@kcl.ac.uk.
authors.forename: Julia A
authors.initials: JA
authors.lastname: Wendon
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D015331:Cohort Studies; D003362:Cost-Benefit Analysis; D005260:Female; D017048:Health Care Costs; D006295:Health Resources / Q000706:statistics & numerical data; D006801:Humans; D007362:Intensive Care Units / Q000191:economics; D008099:Liver / Q000503:physiopathology*; D008103:Liver Cirrhosis / Q000191:economics* / Q000401:mortality / Q000503:physiopathology*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D011446:Prospective Studies; D012189:Retrospective Studies; D015996:Survival Rate; D055815:Young Adult