title: Predictors of Mortality in the Critically Ill Cirrhotic Patient: Is the Model for End-Stage Liver Disease Enough?
abstract: BACKGROUND
  Critically ill cirrhotics require liver transplantation urgently, but are at high risk for perioperative mortality. The Model for End-stage Liver Disease (MELD) score, recently updated to incorporate serum sodium, estimates survival probability in patients with cirrhosis, but needs additional evaluation in the critically ill. The purpose of this study was to evaluate the predictive power of ICU admission MELD scores and identify clinical risk factors associated with increased mortality.
  
  
  METHODS
  This was a retrospective review of cirrhotic patients admitted to the ICU between January 2011 and December 2014. Patients who were discharged or underwent transplantation (survivors) were compared with those who died (nonsurvivors). Demographic characteristics, admission MELD scores, and clinical risk factors were recorded. Multivariate regression was used to identify independent predictors of mortality, and measures of model performance were assessed to determine predictive accuracy.
  
  
  RESULTS
  Of 276 patients who met inclusion criteria, 153 were considered survivors and 123 were nonsurvivors. Survivor and nonsurvivor cohorts had similar demographic characteristics. Nonsurvivors had increased MELD, gastrointestinal bleeding, infection, mechanical ventilation, encephalopathy, vasopressors, dialysis, renal replacement therapy, requirement of blood products, and ICU length of stay. The MELD demonstrated low predictive power (c-statistic 0.73). Multivariate analysis identified MELD score (adjusted odds ratio [AOR] = 1.05), mechanical ventilation (AOR = 4.55), vasopressors (AOR = 3.87), and continuous renal replacement therapy (AOR = 2.43) as independent predictors of mortality, with stronger predictive accuracy (c-statistic 0.87).
  
  
  CONCLUSIONS
  The MELD demonstrated relatively poor predictive accuracy in critically ill patients with cirrhosis and might not be the best indicator for prognosis in the ICU population. Prognostic accuracy is significantly improved when variables indicating organ support (mechanical ventilation, vasopressors, and continuous renal replacement therapy) are included in the model.
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA. Electronic address: Alagappan.Annamalai@cshs.org.
authors.forename: Alagappan
authors.initials: A
authors.lastname: Annamalai
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Megan Y
authors.initials: MY
authors.lastname: Harada
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Melissa
authors.initials: M
authors.lastname: Chen
authors.affiliation: Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Tram
authors.initials: T
authors.lastname: Tran
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Ara
authors.initials: A
authors.lastname: Ko
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Eric J
authors.initials: EJ
authors.lastname: Ley
authors.affiliation: Center for Neurosurgical Outcomes Research, Department of Neurosurgery, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Miriam
authors.initials: M
authors.lastname: Nuno
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Andrew
authors.initials: A
authors.lastname: Klein
authors.affiliation: Department of Surgery, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Nicholas
authors.initials: N
authors.lastname: Nissen
authors.affiliation: Department of Medicine, Cedars-Sinai Medical Center, Los Angeles, CA.
authors.forename: Mazen
authors.initials: M
authors.lastname: Noureddin
mesh_terms: D000368:Aged; D003422:Critical Care; D016638:Critical Illness; D058625:End Stage Liver Disease / Q000209:etiology* / Q000401:mortality* / Q000628:therapy; D005260:Female; D006760:Hospitalization; D006801:Humans; D008103:Liver Cirrhosis / Q000209:etiology / Q000401:mortality* / Q000628:therapy; D008111:Liver Function Tests; D008297:Male; D008875:Middle Aged; D011237:Predictive Value of Tests; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index