title: Advances in management and prognostication in critically ill cirrhotic patients.
abstract: OBJECTIVE
  To provide an update on the recent publications for the management and prognostication of critically ill cirrhotic patients before and after liver transplant.
  
  
  RESULTS
  The CLIF Acute-oN-ChrONicLIver Failure in Cirrhosis (CANONIC) study recently derived an evidence-based definition of acute-on-chronic liver failure (ACLF): hepatic decompensation; organ failure [predefined by the Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA)]; and high 28-day mortality rate. Although Sequential Organ Failure Assessment (SOFA) appears to be more accurate in predicting ICU and hospital mortality in ACLF patients, CLIF-SOFA has been derived specifically for critically ill cirrhotic patients, including those not receiving mechanical ventilation. Recent data suggest that a lower transfusion target in esophageal variceal bleeding (<7 g/l) is safe. Newly defined 'cirrhosis-associated acute kidney injury (AKI)' correlates with mortality, organ failure and length of hospital stay. Although the SOFA score appears to perform better than liver-specific scoring systems [Model for End-stage Liver Disease (MELD) and Child-Pugh scores], neither MELD nor SOFA appears to independently predict posttransplant survival; however, correlated with lengths of ICU and hospital stay. For patients declined for liver transplant, palliative care referral and appropriate goals of care are rarely achieved.
  
  
  CONCLUSIONS
  New definitions for ACLF, cirrhosis-associated AKI and the CLIF-SOFA may improve the discrimination between survivors and nonsurvivors with ACLF. Predicting futility postliver transplant based on preliver transplant severity of illness still poses significant challenges.
authors: aDivision of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta bDivision of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada.
authors: Constantine J
authors: CJ
authors: Karvellas
authors: Sean M
authors: SM
authors: Bagshaw
mesh_terms: D058186:Acute Kidney Injury / Q000401:mortality / Q000628:therapy*; D003422:Critical Care / Q000379:methods; D016638:Critical Illness / Q000401:mortality / Q000628:therapy*; D005260:Female; D006801:Humans; D008103:Liver Cirrhosis / Q000401:mortality / Q000628:therapy*; D016031:Liver Transplantation / Q000379:methods* / Q000401:mortality; D008297:Male; D063305:Organ Dysfunction Scores; D063868:Patient Outcome Assessment; D017410:Practice Guidelines as Topic; D011379:Prognosis; D012720:Severity of Illness Index