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Multicenter Study
. 2025 Sep;45(9):e70264.
doi: 10.1111/liv.70264.

Breaking Barriers for Intensive Care Admission in Patients With Advanced HCC on Immunotherapy

Marta Fortuny  1   2   3 , Leonardo G da Fonseca  4 , Manon Allaire  5 , Rocío Sánchez  6 , Jean-Charles Nault  7   8 , Massimo Iavarone  9   10 , Sofia Ridolfo  9   11 , Sonia Pascual  3   12 , Raquel Jimeno  13 , Mariona Calvo  14 , Raimon Rifà  15 , Marco Sanduzzi-Zamparelli  1   2   3 , Natalia Jiménez-Esquivel  16 , Sarah Mouri  5 , Mercedes Iñarrairaegui  3   6   17 , Josepmaria Argemi  3   17   18   19 , Tania Hernaez  20 , José Enrique Lorenzo-Barreto  21 , María Teresa Ferrer  22 , Susana Coll  23 , Ángela Lamarca  24 , Juan Ignacio Marin  25 , Enric Reverter  16 , Ana María López  26 , Alberto Lue  27 , María Varela  28 , Ana Matilla  3   29 , Javier Fernández  3   16   30   31 , Maria Reig  1   2   3   31
Affiliations
Multicenter Study

Breaking Barriers for Intensive Care Admission in Patients With Advanced HCC on Immunotherapy

Marta Fortuny et al. Liver Int. 2025 Sep.

Abstract

Background and aims: Intensive Care Unit (ICU) admission is usually denied to patients with advanced hepatocellular carcinoma (HCC) due to the perceived poor prognosis associated with both cirrhosis and liver cancer. However, immunotherapy based on immune checkpoint inhibitors (ICI) has transformed the treatment landscape, and the role of critical care is becoming more relevant in managing adverse events. We aim to assess the outcome of patients with advanced HCC treated with ICI admitted to the ICU.

Methods: We evaluated patients treated with ICI combinations across 20 medical centres globally between November 2012 and April 2024. Demographic data, ICI types, causes of admission, organ support, and mortality in the short and medium term were recorded.

Results: Of 1065 patients, 47 (4.4%) were admitted to the ICU. Most were male (76.6%) with cirrhosis (93.6%), and 59.7% received ICI as first-line therapy. The primary reasons for ICU admission were immune-related adverse events (irAE) in 46.8% and variceal bleeding in 29.8%. The median time to ICU admission was 115 days [IQR 38-202] after the initiation of ICI treatment. Among patients admitted due to irAEs, the median time was 51 days [IQR 31-137]. ICU mortality was 25.5%. Two-thirds were alive 28 days post-ICU discharge, with 3- and 6-month survival rates of 83% and 69%. Of the 61.3% of survivors, they were rechallenged with ICI or started new HCC therapy.

Conclusions: irAEs are the main cause of ICU admission in patients with advanced HCC receiving ICI. Despite the severity, 66% were discharged, and nearly half resumed treatment. These findings highlight the vital role of ICU care in managing HCC patients, challenging the notion of denying them intensive care.

Keywords: adverse events; hepatocellular carcinoma; immunotherapy; intensive care.

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Conflict of interest statement

M.F. Speaker fee: AstraZeneca. L.G.d.F. Research grant: Bayer; Advisory board: AstraZeneca, Bayer, Roche; Speaker fee: Roche, AstraZeneca, Bayer, Sirtex, MSD, BMS. M.A. Roche, AstraZeneca, AbbVie, Gilead. R.S. None. J.‐C.N. Research grants from Ipsen and Bayer. M.I. Speaker Bureau and Advisory Board: Roche, Astra Zeneca, Bayer, Roche Diagnostics, Gilead, MSD, EISAI, IPSEN. S.R. None. S.P. Advisory Board: AstraZeneca, Roche; Speaker Fee: Roche, AstraZeneca, Eisai; Travel Grant: AbbVie, Gilead, Roche. R.J. None. M.C. Advisory Board: Roche, Eisai, MSD, AstraZeneca; Travel grant: Roche. R.R. Sponsored Lectures (National): Advanz Farm. Other COI: Conference attendance and educational activities: Gilead, Abbie, Roche, Advanz. M.S.‐Z. Speaker fees: Bayer; Travel grants: Bayer, BTG, MSD‐Eisai, and Roche. N.J.‐E. None. S.M. None. M.I. None. J.A. Speaker: Pfizer, AZ, Roche, Travel grants: Roche, AZ, Research Grants: Roche. T.H. Speaker fee: Eisai, AstraZeneca; Travel Grant: Roche. J.E.L.‐B. Medical training (consultant): Roche, BMS, Servier, Pfizer, Sanofi, Janssen, Ipsen, Merck, Amgen, Travel grants for conferences: Roche, Ipsen, BMS, Pfizer, Servier, Sanofi, Merck, Amgen. M.T.F. Speaker fee: Eisai, Roche; Gilead; Travel Grants: Eisai, Roche, Astrazeneca, Boston Scientific, Gilead. S.C. Travel expenses and congress registrations Roche. A.L. Travel and educational support from Ipsen, Pfizer, Bayer, AAA, SirtEx, Novartis, Mylan, Delcath Advanz Pharma and Roche; Speaker honoraria from Merck, Pfizer, Ipsen, Incyte, AAA/Novartis, QED, Servier, Astra Zeneca, EISAI, Roche, Advanz Pharma and MSD; Advisory and consultancy honoraria from EISAI, Nutricia, Ipsen, QED, Roche, Servier, Boston Scientific, Albireo Pharma, AstraZeneca, Boehringer Ingelheim, GENFIT, TransThera Biosciences, Taiho and MSD; Principal Investigator‐associated Institutional Funding form QED, Merck, Boehringer Ingelheim, Servier, Astra Zeneca, GenFit, Panbela Therapeutics, Novocure GmbH, Camurus AB, Albireo Pharma, Taiho, TransThera, Jazz Therapeutics and Roche; Member of the Knowledge Network and NETConnect Initiatives funded by Ipsen. J.I.M. Speaker Fee: Roche, Astra Zeneca, Knight, Bayer, Gilead. E.R. none. A.M.L. Speaking fee: Amgen, Astra Zeneca, Bristol‐Myers, Eisai, MSD, Roche, Servier. Advisory Board: Amgen, Astra Zeneca, Eisai, Roche. A.L. Speaker in educational activities supported by industries (Eisai, Astellas Pharma S.A., Roche Farma, Advanz Pharma). M.V. Lecture fees, consulting work, travel support, and congress registration: Astrazeneca, Roche, Boston. A.M. Speaker in educational activities, lecture fees, consulting work, travel support, and congress registration: Astrazeneca, Roche, Boston, EISAI, and Sirtex. J.F. None. M.R. Consultant or Advisory Role: AstraZeneca, Bayer, BMS, Eli Lilly, Geneos, Ipsen, Merck, Roche, Universal DX, Boston Scientific, Engitix Therapeutics, Parabilis Medicines Inc.; Speaking: AstraZeneca, Bayer, BMS, Eli Lilly, Gilead, Roche, Biotoscana Farma.; Travel support: Astrazeneca, Roche, Bayer, BMS, Lilly, Ipsen; Principal or sub‐Investigator of drug under development: Abbvie, BMS, Adaptimmune, Nerviano, Medivir, Bayer, Ipsen, Astrazeneca, Terumo, Incyte, Roche, Boston Scientific, Medivir; Grant Research Support (to the institution): Bayer, Ipsen; Educational Support (to the institution): Bayer, Astrazeneca, Eisai‐ Merck MSD, Roche, Ipsen, Lilly, Terumo, BMS, Next, Boston Scientific, Ciscar Medical, Eventy C3 LLC (Egypt).

Figures

FIGURE 1
FIGURE 1
Flowchart of patients admitted to the ICU based on the cause of admission and outcome at discharge. ICU, intensive care unit, irAE, immune‐related adverse event.
FIGURE 2
FIGURE 2
(A) Kaplan–Meier survival curve at 28 days, 3, and 6 months after ICU admission in the whole cohort. (B) Kaplan–Meier survival curve at 3, and 6 months among patients alive 28 days after ICU discharge. ICU, intensive care unit; irAE, immune‐related adverse event.
FIGURE 3
FIGURE 3
Proportion of patients rechallenged/subsequent HCC treatment, no rechallenged, and death within admission or at 28 days, based on the cause of admission. HCC, hepatocellular carcinoma; irAE, immune‐related adverse event.
See this image and copyright information in PMC

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