Risk factors and outcomes of acute respiratory distress syndrome in critically ill patients with cirrhosis

Abstract

Aim: Prior randomized controlled trials of acute respiratory distress syndrome (ARDS) excluded critically ill patients with cirrhosis. Data regarding risk factors for ARDS development and outcomes from ARDS in patients with cirrhosis are scarce. We sought to characterize outcomes from ARDS in patients with cirrhosis.

Methods: An observational cohort of patients with cirrhosis admitted to an intensive care unit at a high-volume liver transplant center between 1 January 2012 and 31 December 2014 were reviewed. ARDS cases were identified according to the Berlin definition. Potential risk factors were examined in multivariable logistic regression analysis for ARDS development. Outcomes including in-hospital mortality were compared between ARDS and non-ARDS patients.

Results: A total of 559 patients met the inclusion criteria and 45 (8.1%) developed ARDS. Differences between ARDS and non-ARDS patients included sepsis, Model for End-Stage Liver Disease - Sodium score, and Sequential Organ Failure Assessment score. In-hospital mortality was higher in cirrhotic patients with ARDS compared with those without ARDS (82.2% vs. 27.6%, P < 0.001). In multivariable analysis, acute-on-chronic liver failure (OR 8.69, 95% CI 2.28-33.18, P < 0.01) and shock on intensive care unit admission (OR 3.13, 95% CI 1.57-6.24, P = 0.001) were associated with ARDS development, whereas etiology of cirrhosis or alcohol use were not.

Conclusions: Acute-on-chronic liver failure and shock on intensive care unit admission were risk factors for ARDS development, whereas etiology of cirrhosis and alcohol were not. Mortality from ARDS was markedly increased in patients with cirrhosis. Early recognition and treatment for infection might be important for improving the high mortality in this group of patients.

Keywords: acute respiratory distress syndrome; alcohol; cirrhosis; sepsis; shock.

Figure 1.

Multivariable logistic regression for risk factors and predisposing conditions for ARDS development. Candidate variables with p<0.2 in the univariable analysis were examined in a multivariable logistic regression analysis. These included sepsis, male sex, diabetes, shock on admission, and renal dysfunction, all examined as dichotomous variables. Cirrhosis type as a dichotomous variable for alcoholic cirrhosis (yes or no) and MELD-Na score (as a continuous variable) were forced into the model because they were the primary aims of this study. ACLF was also added into the model to determine its association with ARDS. Results were as follows: sepsis (OR 2.59, 95% CI 0.94–7.13, p=0.07), male sex (OR 1.58, 95% CI 0.80–3.15, p=0.19), diabetes (OR 1.75, 95% CI 0.87–3.54, p=0.12), alcoholic cirrhosis (OR 1.15, 95% CI 0.56–2.36, p=0.71), shock on ICU admission (OR 2.24, 95% CI 1.11–4.51, p=0.03), renal dysfunction (OR 0.68, 95% CI 0.31–1.51, p=0.34), MELD-Na (OR 1.03, 95% CI 0.98–1.07, p=0.30), and ACLF (OR 8.69, 95% CI 2.28–33.18, p<0.01).