title: Liver transplantation in the critically ill: a multicenter Canadian retrospective cohort study.
abstract: BACKGROUND
  Critically ill cirrhosis patients awaiting liver transplantation (LT) often receive prioritization for organ allocation. Identification of patients most likely to benefit is essential. The purpose of this study was to examine whether the Sequential Organ Failure Assessment (SOFA) score can predict 90-day mortality in critically ill recipients of LT and whether it can predict receipt of LT among critically ill cirrhosis listed awaiting LT.
  
  
  METHODS
  We performed a multicenter retrospective cohort study consisting of two datasets: (a) all critically-ill cirrhosis patients requiring intensive care unit (ICU) admission before LT at five transplant centers in Canada from 2000 through 2009 (one site, 1990 through 2009), and (b) critically ill cirrhosis patients receiving LT from ICU (n = 115) and those listed but not receiving LT before death (n = 106) from two centers where complete data were available.
  
  
  RESULTS
  In the first dataset, 198 critically ill cirrhosis patients receiving LT (mean (SD) age 53 (10) years, 66% male, median (IQR) model for end-stage liver disease (MELD) 34 (26-39)) were included. Mean (SD) SOFA scores at ICU admission, at 48 hours, and at LT were 12.5 (4), 13.0 (5), and 14.0 (4). Survival at 90 days was 84% (n = 166). In multivariable analysis, only older age was independently associated with reduced 90-day survival (odds ratio (OR), 1.07; 95% CI, 1.01 to 1.14; P = 0.013). SOFA score did not predict 90-day mortality at any time. In the second dataset, 47.9% (n = 106) of cirrhosis patients listed for LT died in the ICU waiting for LT. In multivariable analysis, higher SOFA at 48 hours after admission was independently associated with lower probability of receiving LT (OR, 0.89; 95% CI, 0.82 to 0.97; P = 0.006). When including serum lactate and SOFA at 48 hours in the final model, elevated lactate (at 48 hours) was also significantly associated with lower likelihood of receiving LT (0.32; 0.17 to 0.61; P = 0.001).
  
  
  CONCLUSIONS
  SOFA appears poor at predicting 90-day survival in critically ill cirrhosis patients after LT, but higher SOFA score and elevated lactate 48 hours after ICU admission are associated with a lower probability receiving LT. Older critically ill cirrhosis patients (older than 60) receiving LT have worse 90-day survival and should be considered for LT with caution.
authors: Constantine J
authors: CJ
authors: Karvellas
authors: Thomas
authors: T
authors: Lescot
authors: Peter
authors: P
authors: Goldberg
authors: Michael D
authors: MD
authors: Sharpe
authors: Juan J
authors: JJ
authors: Ronco
authors: Eberhard L
authors: EL
authors: Renner
authors: Hina
authors: H
authors: Vahidy
authors: Zafrina
authors: Z
authors: Poonja
authors: Prosanto
authors: P
authors: Chaudhury
authors: Norman M
authors: NM
authors: Kneteman
authors: Markus
authors: M
authors: Selzner
authors: Earl F
authors: EF
authors: Cook
authors: Sean M
authors: SM
authors: Bagshaw
mesh_terms: D000328:Adult; D002170:Canada / Q000453:epidemiology; D015331:Cohort Studies; D016638:Critical Illness / Q000401:mortality* / Q000628:therapy*; D005260:Female; D006801:Humans; D016031:Liver Transplantation / Q000401:mortality* / Q000639:trends*; D008297:Male; D008875:Middle Aged; D009026:Mortality / Q000639:trends; D012189:Retrospective Studies
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