Identification of patients with acute-on-chronic liver failure(ACLF) who will benefit from ongoing support on intensive care unit(ICU) remains a challenge. There is no agreed marker of futility or time-point. There has been recent consensus regarding the definition of ACLF grades, and chronic liver failure-sequential organ failure assessment(CLIF-SOFA) score has been adopted. We aimed to determine if evolution in CLIF-SOFA or other markers of disease severity can predict mortality and survival in ACLF patients admitted to ICU.Methods
Prospectively recorded data was collected on 48 ACLF patients admitted to ICU at Guy’s and St Thomas’ hospital, a tertiary non-transplant centre, from May 2013 – May 2016. Scores were calculated at D0, D2, D5, D7.Results
The majority were male (n=34,700.8%), mean age was 57.4±10.3 years and major aetiologies were ALD (n=34,700.8%) and viral hepatitis (n=11,290.2%). The major indication for ICU admission was infection (n=29,600.4%). Mean Child-Pugh(CP) score on admission to ICU was 12±2 and the mean MELD 24±9. Mortality at 7, 28 and 90 days was 16/48 (33.3%), 30/48 (62.5%), 36/48 (75%).Results
The best predictive model proved to be difference in CLIF-SOFA (‘delta C-SOFA’) scores between D2 and D5 or D7. Mean delta C-SOFA D2-D5 was −2.25±1.9 and mean delta C-SOFA D2-D7 was −3.36±2 for survivors compared to 0.19±1.73(p<0.001) and 0±2.58(p=0.001) for deceased at 90 days, with area under curve(AUC) of 0.839 and 0.835, respectively.Results
The mean survival time (days) for patients with improvement in delta C-SOFA between D2 and D5/D7 was 837±144 and 814±149 vs patients with worsening or static scores 33.8±14.5 (p<0.001) and 37.6±18 (p<0.001). The negative predictive value at D5 and D7 was 95.5% and 94.1%, respectively.Results
Other prognostic scores at a single time point on D7 predicted survival at D28 and D90 with AUC of: CP (0.75/0.67), MELD (0.73/0.79), UKELD (0.79/0.84), ACLF (0.75/0.78) and CLIF-SOFA (0.75/0.83).Conclusions
The evolution in CLIF-SOFA score between D2 and D5/7 is superior to evolution in other scores and scores assessed at single time points when predicting 90 day survival. The delta C-SOFA at D5 and D7 are comparable, thus delta C-SOFA D2-D5 may be used to guide therapeutic decisions.