Comparison of General and Liver-Specific Prognostic Scores in Their Ability to Predict Mortality in Cirrhotic Patients Admitted to the Intensive Care Unit

Abstract

Introduction: Acute Physiology and Chronic Health Evaluation (APACHE) II and III and Sequential Organ Failure Assessment (SOFA) are prognostic scores commonly used in the intensive care unit (ICU). Their accuracy in predicting mortality has not been adequately evaluated in comparison to prognostic scores commonly used in critically ill cirrhotic patients with acute decompensation (AD) or acute-on-chronic liver failure (ACLF).

Aims: This study was conducted to evaluate the performance of prognostic scores, including APACHE II, SOFA, Chronic Liver Failure Consortium (CLIF-C) SOFA, Child-Turcotte-Pugh (CPS), Model for End-Stage Liver Disease (MELD), MELD-Na, MELD to serum sodium ratio (MESO) index, CLIF-C organ failure (CLIF-C OF), CLIF-C ACLF, and CLIF-C AD scores, in predicting mortality of cirrhotic patients admitted to the ICU. Patients and Methods. A total of 382 patients (280 males, mean age 67.3 ± 10.6 years) with cirrhosis were retrospectively evaluated. All prognostic scores were calculated in the first 24 hours of ICU admission. Their ability to predict mortality was measured using the analysis of the area under the receiver operating characteristic curve (AUC).

Results: Mortality was observed in 31% of the patients. Analysis of AUC revealed that CLIF-C OF (0.807) and CLIF-SOFA (0.776) had the best ability to predict mortality in all patients, but CLIF-C OF (0.749) had higher prognostic accuracy in patients with ACLF. CLIF-SOFA, SOFA, and CLIF-C AD had the highest AUC values in patients with AD, with no statistical difference (p=0.971).

Conclusions: When compared to other general or liver-specific prognostic scores, CLIF-C OF, CLIF-SOFA, SOFA, and CLIF-C AD have good accuracy to predict mortality in critically ill patients with cirrhosis and patients with AD. According to the clinical scenario, different scores should be used to provide prognosis to patients with cirrhosis in the ICU.

Figure 1

Mortality according to the number of organ failures defined by (a) CLIF-C and (b) NACSELD criteria. OF, organ failure; CLIF-C, Chronic Liver Failure Consortium; NACSELD, North American Consortium for the Study of End-Stage Liver Disease.

Figure 2

Comparison of the general and liver-specific prognostic scores to predict in-hospital mortality by AUROC in (a) patients with ACLF and (b) AD of cirrhosis. ACLF, acute-on-chronic liver failure; AD, acute decompensation; CLIF-C, Chronic Liver Failure Consortium; APACHE II, Acute Physiology and Chronic Health Evaluation II; MELD, Model for End-Stage Liver Disease; MELD-Na, sodium MELD; CTP, Child–Turcotte–Pugh; SOFA, Sequential Organ Failure Assessment; CLIF-SOFA, CLIF Sequential Organ Failure Assessment; CLIF-C OF, CLIF-C organ failure.

Figure 3

Comparison of general and liver-specific prognostic scores calculated on day 1 to predict in-hospital mortality by receiver operating characteristic curves in all patients either with ACLF or AD of cirrhosis. ACLF, acute-on-chronic liver failure; CLIF-C, Chronic Liver Failure Consortium; APACHE II, Acute Physiology and Chronic Health Evaluation II; MELD, Model for End-Stage Liver Disease; MELD-Na, sodium MELD; CTP, Child–Turcotte–Pugh; SOFA, Sequential Organ Failure Assessment; CLIF-SOFA, CLIF Sequential Organ Failure Assessment; CLIF-C OF, CLIF-C organ failure.

Figure 4

(a) Curves of sensibility and specificity relative to different cut-off values (TG-ROC curves) of the mortality prognostic scores and sensibility and specificity of the optimal cut-off point in 382 patients either with ACLF or AD of cirrhosis. (b) Curves of sensibility and specificity relative to different cut-off values (TG-ROC curves) of the mortality prognostic scores and sensibility and specificity of the optimal cut-off point in 178 patients with ACLF of cirrhosis. (c) Curves of sensibility and specificity relative to different cut-off values (TG-ROC curves) of the mortality prognostic scores and sensibility and specificity of the optimal cut-off point in 204 patients with AD of cirrhosis.