The pre-deterioration MELD-Na score is the best indicator of long term mortality for cirrhotic patients in ICU

Background: Assessing suitability for ICU of a patient with cirrhosis is difficult and there is little data on long‐ term outcomes. The aim was to prospectively examine the predictors of 12 month post ICU discharge mortality among patients with cirrhosis in two non‐transplant metropolitan hospitals. Methods: All patients with cirrhosis were recruited at the time of ICU admission, between April 2016 and March 2019. Patient demographics, reasons for ICU admission and 12 month mortality rates were collected. Liver‐specific scores (Child‐Pugh, MELD‐Na and CLIF‐C‐ACLF) and ICU prognostic scores (SOFA, SAPS2 and APACHE) were calculated. We also included our own pre‐acute deterioration MELD‐Na and Child Pugh scores based on the results between 1‐6 months prior to ICU admission. The primary outcome measure was all‐cause mortality at 12 months post ICU discharge. The ability of the scores above to predict the primary outcome was compared using area under receiver operating characteristic curves (AUROC). Results: Sixty‐four patients had 12 month mortality data, 71% males, mean age of 57.2 years. The main indications for ICU were: gastrointestinal haemorrhage (n = 33); sepsis (n = 11); hypotension (n = 11); hepatic encephalopathy (n = 7); post elective surgery (n = 3); cardiac arrhythmia (n = 2); other (n = 3). The aetiologies of cirrhosis were: alcohol (n = 56); non‐alcoholic steatohepatitis (n = 9); hepatitis C (n = 7); and other (n = 6). The 12 month mortality overall was 53% (n = 23), the majority of deaths were from progressive liver failure (n = 16). The best predictor of 12 m mortality was the pre‐acute deterioration MELD‐Na score (AUC = 0.815). This was higher than the pre‐deterioration Child Pugh Score (AUC = 0.638), the MELD‐Na scores (AUC = 0.501) and Child Pugh scores (AUC = 0.625) at time of ICU admission, and the ICU prognostic scores (SOFA AUC = 0.808, SAPS2 AUC = 0.738, APACHE 2 AUC = 0.588 and ACLF‐CLF AUC = 0.658). Among patients who had MELD‐Na scores ≥21 at the time of ICU admission, those who had a pre‐deterioration MELD‐Na score ≥21 had a mortality rate of 100%, whereas those with pre‐deterioration MELD‐Na score < 21 had a lower mortality rate of 52% (Log Rank p = 0.024). Conclusion: The pre‐acute deterioration MELD‐Na score is the best predictor of long‐term survival after ICU. Patients’ degree of decompensation at baseline should guide decision making around ICU admission more than disease scores at time of ICU referral, when these scores may be temporarily elevated due to reversible illness.