Allocation of patients with liver cirrhosis and organ failure to intensive care: Systematic review and a proposal for clinical practice

Abstract

Aim: To propose an allocation system of patients with liver cirrhosis to intensive care unit (ICU), and developed a decision tool for clinical practice.

Methods: A systematic review of the literature was performed in PubMed, MEDLINE and EMBASE databases. The search includes studies on hospitalized patients with cirrhosis and organ failure, or acute on chronic liver failure and/or intensive care therapy.

Results: The initial search identified 660 potentially relevant articles. Ultimately, five articles were selected; two cohort studies and three reviews were found eligible. The literature on this topic is scarce and no studies specifically address allocation of patients with liver cirrhosis to ICU. Throughout the literature, there is consensus that selection criteria for ICU admission should be developed and validated for this group of patients and multidisciplinary approach is mandatory. Based on current available data we developed an algorithm, to determine if a patient is candidate to intensive care if needed, based on three scoring systems: premorbid Child-Pugh Score, Model of End stage Liver Disease score and the liver specific Sequential Organ Failure Assessment score.

Conclusion: There are no established systems for allocation of patients with liver cirrhosis to the ICU and no evidence-based recommendations can be made.

Keywords: Allocation; Cirrhosis; Failure; Intensive care; Treatment.

Figure 1

Flowchart of trials. Flowchart of search string.

Figure 2

Acute on Chronic Liver Failure. The green line illustrates a patient with stable cirrhosis (i.e., Child-Pugh class A/B) developing acute on chronic liver failure (ACLF). The red line illustrates a patient with progressive chronic liver failure (i.e., a patients with Child C cirrhosis and refractory ascites) developing ACLF. The Y-axis (Prognosis) is based on Child Pugh score or MELD score and the performance status before ACLF develops and CLIF-SOFA score after ACLF. The threshold “deterioration in organ function” represents a level with i.e. increase in creatinine or oxygen demand without organ failure. The threshold “organ failure” is as defined in the CLIF-SOFA score and “point of no return” is a state of multiorgan failure without reversibility.

Figure 3

Proposal of a clinical system to identify candidates for intensive care if indicated. Algorithm based on three scoring systems: Child-Pugh Score, Model of End stage Liver Disease score (MELD) and Sequential Organ Failure Assessment score (CLIF-SOFA). ACLF: Acute on chronic liver failure; ICU: Intensive care unit.

Figure 4

First Chronic Liver Allocation Scoring system. Danish civil registration number, a unique 10-digit personal identification number assigned to every Danish citizen at birth since 1968. HE: Hepatic encephalopathy; CP Score: Child Pugh Score; MAP: Mean arterial pressure; SAT: Oxygen saturation (%); Varice Haemorr: Variceal haemorrhage; S.B. Peritonitis: Spontaneous bacterial peritonitis; Alko. Hepatitis: Alcoholic hepatitis; HRS: Hepato renal syndrome; WHO Perform: WHO performance status; ACLF grade: Acute on chronic liver failure grade; First-CLASS: First Chronic Liver Allocation Scoring System; SSN: Social Security Number.