Retrospective evaluation of prognostic score performances in cirrhotic patients admitted to an intermediate care unit

Intermediate Care Units in Internal Medicine

BACKGROUND

Intermediate Care Units (ImCU) have been historically described as an intermediate level of care between standard wards and intensive care units (ICU), and general medical ImCUs have evolved as specifically addressed to high care medical patients. The objective of this study is to explore designs, appropriateness criteria, and quality of care of general medical ImCUs.

METHODS

a comprehensive literature search was performed in electronic database (PubMed/Medline, Embase, Cochrane and Web of Science) up to July 30th 2024 and data about general medical ImCU denominations, settings, processes and outcomes were extracted.

RESULTS

34 studies were included in systematic analyses, the more used nomenclature was ImCU (70.6 %), followed by High Dependency Unit (20.6 %). The median number of beds was 8 [4-11], the nurse-to-patients ratio 1:3.1, and internists involved in comanagement in 40.0 %. Either a step-up from standard wards or a step-down from ICUs role were reported, with a median of 50.8 % [26.2-71.0] of patients directly admitted from Emergency Departments. The main distinctive activities were continuous monitoring and non-invasive ventilation. The median ICU transfer rate was 8.0 % [5.6-12.3], while in-ImCU and in-hospital mortality were 6.2 % [3.6-8.3] and 14.0 % [8.7-19.1], respectively.

CONCLUSIONS

general medical ImCUs are being increasingly recognized as the appropriate setting for high care medical patients but present to date a wide variability of formats. Activity-based admission criteria tailored on each hospital reality could be a process model for adequate patient flow, and quality of care key indicators should consider the functional general medical ImCU role in hospital macro-systems.

Prognosis algorithms for acute decompensation of cirrhosis and ACLF

Accurate prediction of survival in patients with cirrhosis is crucial, as patients who are unlikely to survive in the short-term need to be oriented to liver transplantation and to novel therapeutic approaches. Patients with acute decompensation of cirrhosis without or with organ dysfunction/failure, the so-called acute-on-chronic liver failure (ACLF), have a particularly high short-term mortality. Recognizing the specificity of this clinical situation, dedicated classifications and scores have been developed over the last 15 years, including variables (e.g. organ failures and systemic inflammation) not part of the formerly available cirrhosis severity scores, namely Child-Pugh score or MELD. For patients with acute decompensation of cirrhosis, it led to the development of a dedicated score, the Clif-C-AD score, independently validated. For more severe patients, three different scoring systems have been proposed, by European, Asian and North American societies namely Clif-C-ACLF, AARC score and NASCELD-ACLF respectively. These scores have been validated, and are widely used across the world. The differences and similarities between these scores, as well as their validation and limitations are discussed here. Even if these scores and classifications have been a step forward in favouring homogeneity between studies, and in helping making decisions for individual patients, their predictive value for mortality can still be improved as their area under the ROC curve does not exceed .8. Novel scores including biomarkers reflecting the pathophysiology of acute decompensation of cirrhosis might help reach that goal.

EASL Clinical Practice Guidelines on acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF), which was described relatively recently (2013), is a severe form of acutely decompensated cirrhosis characterised by the existence of organ system failure(s) and a high risk of short-term mortality. ACLF is caused by an excessive systemic inflammatory response triggered by precipitants that are clinically apparent (e.g., proven microbial infection with sepsis, severe alcohol-related hepatitis) or not. Since the description of ACLF, some important studies have suggested that patients with ACLF may benefit from liver transplantation and because of this, should be urgently stabilised for transplantation by receiving appropriate treatment of identified precipitants, and full general management, including support of organ systems in the intensive care unit (ICU). The objective of the present Clinical Practice Guidelines is to provide recommendations to help clinicians recognise ACLF, make triage decisions (ICU vs. no ICU), identify and manage acute precipitants, identify organ systems that require support or replacement, define potential criteria for futility of intensive care, and identify potential indications for liver transplantation. Based on an in-depth review of the relevant literature, we provide recommendations to navigate clinical dilemmas followed by supporting text. The recommendations are graded according to the Oxford Centre for Evidence-Based Medicine system and categorised as 'weak' or 'strong'. We aim to provide the best available evidence to aid the clinical decision-making process in the management of patients with ACLF.

Predictive Factors for the Prognosis of Alcoholic Liver Cirrhosis

Alcoholic liver cirrhosis (ALC) is a disease with multiple complications and is associated with poor prognosis and significant mortality. Identifying risk factors associated with a poor outcome is important to ensure effective treatment and increase life expectancy. We aimed to evaluate the predictive values of complications regarding mortality in ALC. We retrospectively analyzed 1429 patients with ALC hospitalized between January 2019 and April 2022 at the Institute of Gastroenterology and Hepatology Iasi. The electronic medical records were interrogated to obtain information about demographic data, complications, comorbidities, and prognostic scores: MELD-Na (model for end-stage liver disease-sodium) and CTP (Child−Turcotte−Pugh). Based on uni- and multivariate analysis, independent predictors of mortality were identified. The mean age at diagnosis was 56.15 ± 11.49 years with a ratio of 2:1 in favor of males. There were 296 deaths (20.8%), most of them during the first hospitalization (208/14.6%). It was observed during the univariate analysis that complications of the disease negatively affected the survival rate, significant values being related to infections (sepsis; OR = 21.98; p < 0.001; spontaneous bacterial peritonitis (SBP) (OR = 11.94; p < 0.001) and hepatorenal syndrome (HRS) (OR = 9.35; p < 0.001). The independent predictors, confirmed by multivariate analysis, were the association of variceal bleeding, infections, and hepatic encephalopathy or ascites, each combination being responsible for two out of 10 of the deaths during the first admission. The prognosis of the disease was negatively influenced by the worsening of liver dysfunction and the appearance of complications. The main predictors of mortality were infections, hepatic encephalopathy, variceal bleeding, and hepatorenal syndrome. Improving compliance and strict application of specific follow-up and treatment strategies could contribute to a better prognosis of patients with alcoholic liver cirrhosis.

Predicting in-hospital mortality of cirrhotic patients hospitalized with hepatic encephalopathy

Background

Hepatic encephalopathy (HE) is a serious condition associated with high rates of mortality. Many scoring systems are used to predict the outcome of HE in patients admitted to the intensive care unit (ICU). The most used scores are Child-Turcotte-Pugh (CTP), Model for End-stage Liver Disease (MELD), Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II). These scores were thoroughly investigated in HE associated with acute liver failure (type A). In the present study, we aimed to evaluate the prognostic value of these scores in patients with HE on a background of liver cirrhosis (type C). Two hundred cirrhotic patients hospitalized with HE were included in the study. Diagnosis and classification of HE were based on the West Haven criteria. APACHE II, CLIF-SOFA, MELD, MELD-Na, and CTP scores were calculated for all patients within the first 24 h after admission. According to survival outcomes, patients were categorized into either improved or deceased. Demographic, clinical, and laboratory data as well as prognostic scores were compared in both deceased and improved groups. The receiver operating characteristic (ROC) curve was plotted, and the area under the ROC curve (AUROC) was calculated for each score. Backward logistic regression analysis was used to identify the predictors of mortality.

Results

60.5% of patients were males. The mean age was 61.09 ± 8.94 years. The main precipitating factors of HE was infections predominantly spontaneous bacterial peritonitis (n = 108, 54.0%) followed by variceal bleeding (n = 39, 19.5%). All scores were significantly higher in the deceased patients. AUROC were 0.734 (CI95% 0.666–0.803), 0.717 (CI95% 0.647–0.787), 0.663 (CI95% 0.589–0.738), 0.626 (CI95% 0.549–0.704), and 0.609 (CI95% 0.531–0.686) for CLIF-SOFA, MELD-Na, MELD, APACHE II, and CTP scores, respectively. MELD, MELD-Na, and CLIF-SOFA scores were the independent predictors of mortality. Among these scores, CLIF-SOFA was the strongest independent predictor of mortality (OR = 1.142, CI95% = 0.888–1.467, p = 0.001).

Conclusions

CLIF-SOFA score was superior to other prognostic scores in predicting mortality in hospitalized patients with HE type C.

A prediction model for 30-day deaths of cirrhotic patients in intensive care unit hospitalization

The aim of this study was to establish a prediction model for 30-day deaths of cirrhotic patients in intensive care unit.A case-control study involving 1840 patients was conducted in the Medical Information Mart of the Intensive Care Database III version 1.4. The logistic regression with L1 regularization was used to screen out the variables. The 30-day in-hospital death was used as the dependent variable and the selected variables were used as the independent variable to build a random forest model. The performance of the model was validated by the internal validation.The variables screened by logistic regression analysis were the age, heart rate, respiratory rate, systolic blood pressure, diastolic blood pressure, Oxygen saturation, white blood cells, platelets, red cell distribution width, glucose, blood urea nitrogen, bicarbonate, total bilirubin, hematocrit, alanine transaminase, aspartate transaminase, bilirubin, Simplified Acute Physiology Score II and Sequential Organ Failure Assessment. The areas under the curve of the random forest model based on these variables was 0.908, and the performance of this model were internally validated with an areas under the curve of 0.801. The random forest model displayed that Simplified Acute Physiology Score, Sequential Organ Failure Assessment, blood urea nitrogen, total bilirubin and bilirubin were more important predictors for the 30-day death of cirrhotic patients in intensive care unit.A prediction model for death of cirrhotic patients was developed based on a random forest analysis, providing a tool to evaluate the patients with a high risk of 30-day in-hospital deaths to help clinician make preventive intervention to decrease the mortality.

Child-Turcotte-Pugh Score, MELD Score and MELD-Na Score as Predictors of Short-Term Mortality among Patients with End-Stage Liver Disease in Northern India

Background and Objectives

Child-Turcotte-Pugh (CTP), Model for End-Stage Liver Disease (MELD) and MELD-sodium (MELD-Na) scores are used for predicting disease severity and mortality among patients with end-stage liver disease. However, data regarding their usefulness in predicting the short-term outcome of end-stage liver disease are not available in India. This prospective study compared the CTP score, MELD score and MELD-Na score as predictors of short-term outcome among patients with end-stage liver disease.

Methods

CTP, MELD and MELD-Na scores were determined in 171 patients with end-stage liver disease at a tertiary healthcare centre in India at the time of admission, and the concordance (C-) statistics of the three scores for 3-month mortality were assessed and compared. The aetiology of end-stage liver disease and the clinical presentation were determined.

Results

The CTP score, MELD score and MELD-Na score on day 1 were significantly higher among non-survivors than among survivors (p < 0.0001 each). The C-statistic for 3-month mortality for the CTP score was 0.93 (p < 0.0001), that for the MELD score was 0.86 (p < 0.0001) and that for the MELD-Na score was 0.83 (p < 0.0001). The C-statistics of these scores differed significantly for 3-month mortality, and the CTP score was better than the MELD (p < 0.0001) and MELD-Na (p < 0.0001) scores in predicting 3-month mortality.

Conclusions

The CTP, MELD and MELD-Na scores were very good predictors of mortality at 3 months among patients with end-stage liver disease. The CTP score was superior to the MELD and MELD-Na scores in predicting 3-month mortality.

The predictive performance of SAPS 2 and SAPS 3 in an intermediate care unit for internal medicine at a German university transplant center; A retrospective analysis

OBJECTIVE

To analyze and compare the performance of the Simplified-Acute-Physiology-Score (SAPS) 2 and SAPS 3 among intermediate care patients with internal disorders.

MATERIALS AND METHODS

We conducted a retrospective single-center analysis in patients (n = 305) admitted to an intermediate-care-unit (ImCU) for internal medicine at the University Hospital Essen, Germany. We employed and compared the SAPS 2 vs. the SAPS 3 scoring system for the assessment of disease severity and prediction of mortality rates among patients admitted to the ImCU within an 18-month period. Both scores, which utilize parameters recorded at admission to the intensive-care-unit (ICU), represent the most widely applied scoring systems in European intensive care medicine. The area-under-the-receiver-operating-characteristic-curve (AUROC) was used to evaluate the SAPS 2 and SAPS 3 discrimination performance. Ultimately, standardized-mortality-ratios (SMRs) were calculated alongside their respective 95%-confidence-intervals (95% CI) in order to determine the observed-to-expected death ratio and calibration belt plots were generated to evaluate the SAPS 2 and SAPS 3 calibration performance.

RESULTS

Both scores provided acceptable discrimination performance, i.e., the AUROC was 0.71 (95% CI, 0.65-0.77) for SAPS 2 and 0.77 (95% CI, 0.72-0.82) for SAPS 3. Against the observed in-hospital mortality of 30.2%, SAPS 2 showed a weak performance with a predicted mortality of 17.4% and a SMR of 1.74 (95% CI, 1.38-2.09), especially in association with liver diseases and/or sepsis. SAPS 3 performed accurately, resulting in a predicted mortality of 29.9% and a SMR of 1.01 (95% CI, 0.8-1.21). Based on Calibration belt plots, SAPS 2 showed a poor calibration-performance especially in patients with low mortality risk (P<0.001), while SAPS 3 exhibited a highly accurate calibration performance (P = 0.906) across all risk levels.

CONCLUSIONS

In our study, the SAPS 3 exhibited high accuracy in prediction of mortality in ImCU patients with internal disorders. In contrast, the SAPS 2 underestimated mortality particularly in patients with liver diseases and sepsis.

High-dependency units play a key role in the treatment of a Chinese military patient who developed liver failure while abroad

High-dependency units (HDUs) provide high-level care to patients who suffer from single organ failure, with the exception of respiratory failure requiring mechanical ventilation; HDUs serve as an intermediary between general wards and Intensive Care Units. Due to military and civilian needs, our hospital has established a unique HDU for patients with liver disease in China. A Chinese military officer in the United Nations Peacekeeping Forces in South Sudan was transferred to our HDU for liver failure treatment in 2018. The patient's disease status, nutrition, sleep habits, and psychological behaviour were monitored on different scales. The patient was provided with vascular monitoring, telemetry, pulse oximetry, drug treatment, nutritional support, sleep intervention, psychological intervention, and humanistic care by a multidisciplinary treatment team. After treatment, the patient recovered and avoided liver transplantation. Based on the experience with this HDU, this new model may create an efficient treatment process for military and civilian patients with severe liver disease at home or abroad.

Comparison of the prognostic value of Chronic Liver Failure Consortium scores and traditional models for predicting mortality in patients with cirrhosis

BACKGROUND AND AIM

Recently, the European Association for the Study of the Liver - Chronic Liver Failure (CLIF) Consortium defined two new prognostic scores, according to the presence or absence of acute-on-chronic liver failure (ACLF): the CLIF Consortium ACLF score (CLIF-C ACLFs) and the CLIF-C Acute Decompensation score (CLIF-C ADs). We sought to compare their accuracy in predicting 30- and 90-day mortality with some of the existing models: Child-Turcotte-Pugh (CTP), Model for End-Stage Liver Disease (MELD), MELD-Na, integrated MELD (iMELD), MELD to serum sodium ratio index (MESO), Refit MELD and Refit MELD-Na.

METHODS

Retrospective cohort study that evaluated all admissions due to decompensated cirrhosis in 2 centers between 2011 and 2014. At admission each score was assessed, and the discrimination ability was compared by measuring the area under the ROC curve (AUROC).

RESULTS

A total of 779 hospitalizations were evaluated. Two hundred and twenty-two patients met criteria for ACLF (25.9%). The 30- and 90-day mortality were respectively 17.7 and 37.3%. CLIF-C ACLFs presented an AUROC for predicting 30- and 90-day mortality of 0.684 (95% CI: 0.599-0.770) and 0.666 (95% CI: 0.588-0.744) respectively. No statistically significant differences were found when compared to traditional models. For patients without ACLF, CLIF-C ADs had an AUROC for predicting 30- and 90-day mortality of 0.689 (95% CI: 0.614-0.763) and 0.672 (95% CI: 0.624-0.720) respectively. When compared to other scores, it was only statistically superior to MELD for predicting 30-day mortality (p=0.0296).

CONCLUSIONS

The new CLIF-C scores were not statistically superior to the traditional models, with the exception of CLIF-C ADs for predicting 30-day mortality.