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Liver transplantation in the critically ill: a multicenter Canadian retrospective cohort study

Constantine J Karvellas12*, Thomas Lescot3, Peter Goldberg3, Michael D Sharpe4, Juan J Ronco5, Eberhard L Renner6, Hina Vahidy2, Zafrina Poonja2, Prosanto Chaudhury7, Norman M Kneteman8, Markus Selzner6, Earl F Cook9, Sean M Bagshaw1 and the Canadian Liver Failure Study Group

Author Affiliations

1 Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, 3C1.12 Walter C Mackenzie Center, 8440-112 ST NW, Edmonton, Alberta, T6G 2B7, Canada

2 Division of Hepatology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, 130 University Campus NW, Edmonton, Alberta, T6G-2X8, Canada

3 Division of Critical Care Medicine, McGill University, McGill University Health Center, 687 Pine Avenue West, Montreal, Quebec, H3A 1A1, Canada

4 Division of Critical Care Medicine, Western University, London, Ontario, Canada

5 Division of Critical Care Medicine, University of British Columbia, Vancouver General Hospital, 855 West 12th Avenue, Vancouver, British Columbia, V5Z 1M9, Canada

6 Multi-Organ Transplant Program, University Health Network/University of Toronto, 585 University Avenue, Toronto, Ontario, M5G 2N2, Canada

7 Division of Solid Organ Transplantation, McGill University Health Center, 687 Pine Avenue West, Montreal, Quebec, H3A 1A1, Canada

8 Division of Transplantation, Department of Surgery, University of Alberta, 2D4.44 Walter C. Mackenzie Centre, Edmonton, Alberta, T6G 2B7, Canada

9 Department of Epidemiology, Harvard School of Public Health, 677 Huntington Avenue, Boston, Massachusetts 02115, USA

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Critical Care 2013, 17:R28  doi:10.1186/cc12508


See related Letter by Wlodzimirow and Abu-Hanna, http://ccforum.com/content/17/2/426

Published: 9 February 2013

Abstract

Introduction

Critically ill cirrhosis patients awaiting liver transplantation (LT) often receive prioritization for organ allocation. Identification of patients most likely to benefit is essential. The purpose of this study was to examine whether the Sequential Organ Failure Assessment (SOFA) score can predict 90-day mortality in critically ill recipients of LT and whether it can predict receipt of LT among critically ill cirrhosis listed awaiting LT.

Methods

We performed a multicenter retrospective cohort study consisting of two datasets: (a) all critically-ill cirrhosis patients requiring intensive care unit (ICU) admission before LT at five transplant centers in Canada from 2000 through 2009 (one site, 1990 through 2009), and (b) critically ill cirrhosis patients receiving LT from ICU (n = 115) and those listed but not receiving LT before death (n = 106) from two centers where complete data were available.

Results

In the first dataset, 198 critically ill cirrhosis patients receiving LT (mean (SD) age 53 (10) years, 66% male, median (IQR) model for end-stage liver disease (MELD) 34 (26-39)) were included. Mean (SD) SOFA scores at ICU admission, at 48 hours, and at LT were 12.5 (4), 13.0 (5), and 14.0 (4). Survival at 90 days was 84% (n = 166). In multivariable analysis, only older age was independently associated with reduced 90-day survival (odds ratio (OR), 1.07; 95% CI, 1.01 to 1.14; P = 0.013). SOFA score did not predict 90-day mortality at any time. In the second dataset, 47.9% (n = 106) of cirrhosis patients listed for LT died in the ICU waiting for LT. In multivariable analysis, higher SOFA at 48 hours after admission was independently associated with lower probability of receiving LT (OR, 0.89; 95% CI, 0.82 to 0.97; P = 0.006). When including serum lactate and SOFA at 48 hours in the final model, elevated lactate (at 48 hours) was also significantly associated with lower likelihood of receiving LT (0.32; 0.17 to 0.61; P = 0.001).

Conclusions

SOFA appears poor at predicting 90-day survival in critically ill cirrhosis patients after LT, but higher SOFA score and elevated lactate 48 hours after ICU admission are associated with a lower probability receiving LT. Older critically ill cirrhosis patients (older than 60) receiving LT have worse 90-day survival and should be considered for LT with caution.