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. 2023 Sep 29;13(1):96.
doi: 10.1186/s13613-023-01190-1.

Outcomes and time trends of acute respiratory distress syndrome patients with and without liver cirrhosis: an observational cohort

Joris Pensier  1   2 , Audrey De Jong  1   2 , Clément Monet  1   2 , Yassir Aarab  1 , Clément Le Bihan  1 , Mathieu Capdevila  1   2 , Inès Lakbar  1   3 , Lucas Stock  1 , Fouad Belafia  1 , Gerald Chanques  1   2 , Nicolas Molinari  4   5 , Samir Jaber  6   7   8
Affiliations

Outcomes and time trends of acute respiratory distress syndrome patients with and without liver cirrhosis: an observational cohort

Joris Pensier et al. Ann Intensive Care. .

Abstract

Background: In studies prior to lung-protective ventilation, liver cirrhosis in acute respiratory distress syndrome (ARDS) was associated with high mortality rates. Since patients with cirrhosis have been excluded from many trials on ARDS, their outcome when treated with lung-protective ventilation is unclear. The objectives were to assess whether cirrhosis is associated with mortality in ARDS and trends over time in mortality and severity.

Methods: We conducted a retrospective analysis of a prospective observational cohort conducted in a 20-bed tertiary ICU from October 2003 to December 2021. All consecutive adult critically ill patients with ARDS were included. ARDS was defined by the Berlin criteria. The primary outcome was 90 day mortality, assessed with Kaplan-Meier curves and multivariate Cox analysis. Time trends were assessed on 90 day mortality, Sequential Organ-Function Assessment score (SOFA) and non-hepatic SOFA. Ventilation settings were compared between patients with and without cirrhosis.

Results: Of the 7155 patients screened, 863 had a diagnosis of ARDS. Among these ARDS patients, 157(18%) had cirrhosis. The overall 90 day mortality was of 43% (378/863), 57% (90/157) in patients with cirrhosis and 41% (288/706) in patients without cirrhosis (p < 0.001). On survival curves, cirrhosis was associated with 90 day mortality (p < 0.001). Cirrhosis was independently associated with 90 day mortality in multivariate analysis (hazard ratio = 1.56, 95% confidence interval 1.20-2.02). There was no change in mortality over time in ARDS patients with and without cirrhosis. SOFA (p = 0.04) and non-hepatic SOFA (p = 0.02) increased over time in ARDS patients without cirrhosis, and remained stable in ARDS patients with cirrhosis. Tidal volume, positive end-expiratory pressure, plateau pressure and driving pressure were not different between ARDS patients with and without cirrhosis.

Conclusions: Although ARDS management improved over the last decades, the 90 day mortality remained high and stable over time for both ARDS patients with (57%) and without cirrhosis (41%). Nevertheless, the severity of patients without cirrhosis has increased over time, while the severity of patients with cirrhosis has remained stable.

Keywords: Acute respiratory distress syndrome; Cirrhosis; Intensive care unit; Liver failure; Ventilation.

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Conflict of interest statement

Pr. Jaber reports receiving consulting fees from Drager, Medtronic, Baxter, Fresenius-Xenios, Mindray, and Fisher & Paykel. Dr. De Jong reports receiving consulting fees from Medtronic, Dräger, Viatris and Fisher & Paykel. No conflict of interests is reported for other authors.

Figures

Fig. 1
Fig. 1
Flowchart of the study
Fig. 2
Fig. 2
Cumulative 90 day mortality in 706 ARDS patients without cirrhosis and 157 ARDS patients with cirrhosis. p-value < 0.001 by the log-rank test
Fig. 3
Fig. 3
Time trends over the study period in 863 ARDS patients with and without cirrhosis. A 90 day mortality. 90 day mortality (with standard error) during each study year in ARDS patients without cirrhosis (blue bars) and ARDS patients with cirrhosis (red bars). The test for trend was non-significant in the patients without cirrhosis (Cochran–Armitage test, p = 0.55) and in patients with cirrhosis (Cochran–Armitage test, p = 0.62). B SOFA score on ICU admission. SOFA score during each study year in ARDS patients without cirrhosis (blue boxes) and ARDS patients with cirrhosis (red boxes). SOFA: Sequential Organ Failure Assessment. C Non-hepatic SOFA score on ICU admission. SOFA score during each study year in ARDS patients without cirrhosis (blue boxes) and ARDS patients with cirrhosis (red boxes). SOFA: Sequential Organ Failure Assessment
Fig. 4
Fig. 4
Cumulative frequency graphs for ventilatory parameters in ARDS patients with and without cirrhosis. A Tidal volume. B Positive end-expiratory pressure. C Plateau pressure. D Driving pressure
See this image and copyright information in PMC

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