Skip to main content
Download PDF

Critical care outcomes in decompensated cirrhosis: a United States national inpatient sample cross-sectional study

Critical Care volume 28, Article number: 150 (2024) Cite this article

Abstract

Background

Prior assessments of critical care outcomes in patients with cirrhosis have shown conflicting results. We aimed to provide nationwide generalizable results of critical care outcomes in patients with decompensated cirrhosis.

Methods

This is a retrospective study using the National Inpatient Sample from 2016 to 2019. Adults with cirrhosis who required respiratory intubation, central venous catheter placement or both (n = 12,945) with principal diagnoses including: esophageal variceal hemorrhage (EVH, 24%), hepatic encephalopathy (58%), hepatorenal syndrome (HRS, 14%) or spontaneous bacterial peritonitis (4%) were included. A comparison cohort of patients without cirrhosis requiring intubation or central line placement for any principal diagnosis was included.

Results

Those with cirrhosis were younger (mean 58 vs. 63 years, p < 0.001) and more likely to be male (62% vs. 54%, p < 0.001). In-hospital mortality was higher in the cirrhosis cohort (33.1% vs. 26.6%, p < 0.001) and ranged from 26.7% in EVH to 50.6% HRS. Mortality when renal replacement therapy was utilized (n = 1580, 12.2%) was 46.5% in the cirrhosis cohort, compared to 32.3% in other hospitalizations (p < 0.001), and was lowest in EVH (25.7%) and highest in HRS (51.5%). Mortality when cardiopulmonary resuscitation was used was increased in the cirrhosis cohort (88.0% vs. 72.1%, p < 0.001) and highest in HRS (95.7%).

Conclusions

One-third of patients with cirrhosis requiring critical care did not survive to discharge in this U.S. nationwide assessment. While outcomes were worse than in patients without cirrhosis, the results do suggest better outcomes compared to previous studies.

Background

Cirrhosis is a major cause of global morbidity and mortality with annual deaths and hospitalizations continuing to rise [1,2,3,4,5]. In the United States (U.S.) alone, chronic liver disease accounts for nearly 700,000 annual hospitalizations and 44,000 annual deaths [6, 7]. Acute decompensation events in cirrhosis, such as gastrointestinal hemorrhage and hepatic encephalopathy, are associated with high rates of both multiorgan dysfunction and short-term mortality [8,9,10,11]. To optimally manage these life-threatening complications, critical care is sometimes necessary. Indeed, 10% of patients hospitalized for a complication of cirrhosis require intensive care unit (ICU) admission and 3% of all ICU admissions occur for patients with cirrhosis [12, 13]. Historically, outcomes have been considered very poor for patients with complications of decompensated cirrhosis requiring ICU-level care [10, 14,15,16]. Reported ICU mortality rates for patients with cirrhosis have ranged from 29 to 87% [4, 8, 13, 17,18,19,20]. While recent studies have suggested that outcomes in critical care for decompensated cirrhosis may be improving, the generalizability of available data is limited by differences in studied populations and institutions along with low sample sizes and overall outcomes in the U.S. are still unclear [2, 13, 21].

Understanding prognosis is important for providers as it informs clinical care and can help with proper stratification in the management of these patients. It also allows for informed discussions with patients and their families about the utility of aggressive care [22]. In an attempt to objectively demonstrate critical care outcomes in those with cirrhosis admitted to an ICU and allow for future assessments in outcome trends, we utilized the U.S. National Inpatient Sample (NIS) to characterize decompensation type, interventions utilized, and in-hospital mortality.

Methods

Study design and database description

This is a retrospective, cross-sectional study that utilized the NIS to analyze hospitalizations in the U.S. 2016–2019. The NIS is a database that was developed for the Healthcare Cost and Utilization Project (HCUP). It is an all-payer database that approximates a 20-percent stratified sample of U.S. community hospital admissions. After weighting, the NIS can characterize approximately 35 million annual hospitalizations. Basic patient demographic data along with hospital data such as hospital size and region are both available for individual hospitalizations within the NIS. The NIS contains a single principal discharge diagnosis which is considered to be the diagnosis chiefly responsible for the admission. Procedures completed during the hospitalization are also available within the NIS. The NIS is a de-identified database that is publicly available and Institutional Review Board approval was waived.

Study sample and variables

Hospitalizations 2016–2019 requiring critical care with a primary diagnosis of esophageal variceal hemorrhage, hepatic encephalopathy, hepatorenal syndrome, or spontaneous bacteria peritonitis were assessed (Fig. 1). A secondary diagnosis of cirrhosis was also an inclusion criterium. These hospitalizations were compared to hospitalizations requiring critical care in patients who did not have a discharge diagnosis of cirrhosis. Delivery of critical care was defined as having received respiratory intubation, central venous catheter placement or both interventions. All principal diagnoses, secondary diagnoses, and procedures were defined by ICD-10 diagnostic and procedural codes (Table S1). Baseline demographic and clinical data along with hospital-level data were evaluated for each hospitalization with specifically assessed variables found in Table 1.

Fig. 1
figure 1

Derivation of a cohort of hospitalizations requiring critical care for complications of decompensated cirrhosis. Derivation of a comparison cohort of hospitalizations requiring critical care in patients without cirrhosis is also shown

Full size image
Table 1 Demographic and clinical characteristics of hospitalizations requiring critical care for complications of decompensated cirrhosis
Full size table

Outcomes

Clinical outcomes included mortality, the use of renal replacement therapy (RRT) and the use of cardiopulmonary resuscitation (CPR). Outcomes were described for the combined cohort (all four primary diagnoses) and separately for the four unique primary diagnoses; esophageal variceal hemorrhage, hepatic encephalopathy, hepatorenal syndrome and spontaneous bacterial peritonitis. The prevalence of RRT was described and mortality was assessed in those who received RRT and those who did not receive RRT. Similarly, the prevalence of CPR was described as was mortality in those who underwent CPR.

Statistical analysis

The NIS incorporates a self-weighted sample design that is intended to ensure that results are representative of the U.S. inpatient population. The sampling is a stratified systematic random sample of hospitalizations. Weighted results were created using the standard procedures outlined by HCUP and all reported results are weighted. Continuous variables were described with means (with the standard deviation provided for age) and categorical variables, including baseline clinical and hospital level data along with clinical outcomes, were described using proportions. The means of continuous variables were compared with the Student’s t-test. Proportions were compared using chi-square. Hospitalizations with missing variables were not excluded from the study, however, they were not included in proportion calculations that involved the missing variables. STATA, version 17.0 was used for all statistical computations.

Results

Study demographic and clinical characteristics

A total of 12,945 hospitalizations for complications of decompensated cirrhosis were included in the study. The mean age of patients was 58 years (SD = 11.2 years) and 38% of the hospitalizations were for female patients. The majority of the cohort was white (63.8%) with other races comprising 36.2% of the cohort (Table 1). Hepatic encephalopathy was the most common primary diagnosis, accounting for 7485 hospitalizations (57.8%). There were 3130 hospitalizations (24.2%) for esophageal variceal hemorrhage, 1,830 (14.1%) for hepatorenal syndrome, and 500 (3.9%) hospitalizations for spontaneous bacterial peritonitis. Intubation was the sole criterium met for critical care in 69.9% of the hospitalizations while 18.0% of the cohort underwent central venous catheter placement without intubation and 12.1% underwent both procedures. There were 3,724,744 hospitalizations requiring critical care in patients without cirrhosis during the same period of time. In comparison to hospitalizations for patients without cirrhosis, hospitalizations for complications of decompensated cirrhosis tended to occur in younger patients (mean age 58.0 vs. 62.5 years, p < 0.001) and these patients were more likely to be male (61.8% vs. 53.9%, p < 0.001). Additionally, palliative care encounters were more common in hospitalizations for decompensated cirrhosis complications compared to hospitalizations for patients without cirrhosis (21.4% vs. 14.5%, p < 0.001).

In-hospital mortality

In total, 4290 deaths were recorded in patients with complications of decompensated cirrhosis while 990,205 deaths were recorded in patients without cirrhosis. In-hospital mortality for complications of decompensated cirrhosis for all patients was 33.1%, which was significantly higher (p < 0.001) than the 26.6% mortality noted in hospitalizations for patients without a history of cirrhosis (Table 2). Mortality in complications of decompensated cirrhosis ranged from 26.7% in hospitalizations for esophageal variceal hemorrhage to 50.6% in hospitalizations for hepatorenal syndrome (Fig. 2).

Table 2 Clinical outcomes of hospitalizations requiring critical care in patients with complications of decompensated cirrhosis
Full size table
Fig. 2
figure 2

In-hospital mortality for decompensated cirrhosis complications requiring critical care. Results are stratified by primary diagnosis for the hospitalization and the need for renal replacement therapy and cardiopulmonary resuscitation

Full size image

RRT prevalence and outcomes

RRT was utilized in 1580 (12.2%) hospitalizations for decompensated cirrhosis complications, which was higher compared to hospitalizations in patients without cirrhosis (8.4%) (p < 0.001). RRT was most commonly utilized when the primary diagnosis was hepatorenal syndrome (500/1830, 27.3%). In patients who did not undergo RRT (n = 11,365), overall mortality was 31.3% and esophageal variceal bleed remained the condition with the lowest mortality (25.7%) while hepatorenal syndrome had the highest mortality (51.5%). Mortality in hospitalizations for complications of decompensated cirrhosis that received RRT was 46.5% and ranged from 44.4% in cases of hepatic encephalopathy to 62.5% in cases of esophageal variceal hemorrhage. For hospitalizations requiring critical care in patients without cirrhosis, mortality when RRT was utilized was 32.3% which was significantly lower (p < 0.001) than mortality in the decompensated cirrhosis cohort.

CPR prevalence and outcomes

Of the 12,945 hospitalizations for complications of decompensated cirrhosis, CPR was utilized in 710 (5.5%). CPR rates ranged from 4.9% in hospitalizations for hepatic encephalopathy to 6.4% in hospitalizations for esophageal variceal hemorrhage. Death occurred in 88.0% of hospitalizations that included the use of CPR and ranged from 82.5% in cases of esophageal variceal hemorrhage to 95.7% in cases of hepatorenal syndrome. CPR rates were similar between patients who underwent RRT (5.7%) and patients who did not undergo RRT (5.5%, p = 0.86). In comparison, hospitalizations for patients without cirrhosis had a higher rate of CPR (8.4%, < 0.001) and lower mortality when CPR was utilized (72.1%, p < 0.001).

Discussion

One-third of patients requiring critical care for complications of decompensated cirrhosis did not survive-to-discharge in our 4-year U.S. nationwide analysis. These results provide generalizable information on critical care outcomes for patients within the U.S. with decompensated cirrhosis. In addition, we demonstrate an increase in mortality in those requiring RRT as well as poor CPR outcomes in this population.

Overall in-hospital mortality for complications of decompensated cirrhosis was increased compared to hospitalizations for patients without cirrhosis and was within the range of previously reported ICU mortality in patients with cirrhosis (29–87%) [4, 8, 12, 13, 17,18,19,20, 23, 24]. However, it is noteworthy that at 33.1%, our findings were on the lower end of previously reported mortality and therefore highlight the importance of nationwide large cohorts to better understand generalized outcomes. Prior evaluations of critical care outcomes in patients with cirrhosis have largely used ICU admission as an inclusion criterium without specification to whether or not patients underwent respiratory intubation or central line placement [8, 14, 17,18,19]. Patients in the ICU requiring respiratory intubation or the placement of a central venous catheter have been shown to have worse outcomes than those who do not require either [25,26,27]. All subjects in our study underwent respiratory intubation and/or central venous catheter placement. Mortality in our study being on the lower end of previously reported rates despite our inclusion criteria suggests that outcomes are either improving or that previous conclusions were overly pessimistic [2, 8, 10, 13, 28, 29]. Notably, we did include patients who received a liver transplant during the index hospitalizations (n = 400), which is another possible explanation for the relatively low mortality. However, this had relatively little impact in our analysis, as even after excluding those hospitalizations, mortality in our study remained on the lower end of previously reported rates (34.0%).

A large-scale assessment of a combined cohort of patients in Australia and New Zealand found that ICU mortality in those with cirrhosis declined from 44% in 2000 to 29% in 2015 [29]. Another large-scale assessment of patients in the United Kingdom found that mortality in those with cirrhosis admitted to the ICU declined from 58% in 1998 to 46% in 2012 [8]. This trend has been demonstrated in the U.S. as well, with a study by Cheung et al. showing improvement in mortality of intubated patients with cirrhosis from 2005 to 2014 [30]. Advances in the management of complications of cirrhosis, including variceal hemorrhage and hepatorenal syndrome, have been described recently and these, along with improvements in critical care in general, may be responsible for the trend of improvement noted in the literature and supported by our findings [4, 9, 11, 13, 31,32,33].

An important distinction between our study and previous assessments is that we solely evaluated admissions for complications of decompensated liver disease while many of the previous assessments included ICU admissions for any reason in patients with cirrhosis [8, 18, 19, 29]. This may have also contributed to the relatively low mortality in our study if admission reasons not assessed in our study portend high mortality. Sepsis, in particular, warrants mention as infection accounts for approximately 50% of deaths in patients with cirrhosis [34]. While spontaneous bacterial peritonitis was the only infectious complication we specifically evaluated for, prior studies have identified infection as a common trigger for acute decompensation events with concurrent infection present in 66% of cases of upper gastrointestinal bleeding and 64% of cases of hepatic encephalopathy in patients with cirrhosis [35,36,37]. It is therefore likely that infection complicated many of the cases we included despite the primary diagnoses being non-infectious complications of cirrhosis. Our method of evaluation, while limited in regard to comparing to prior studies, provides a study design that can be replicated in future studies to assess trends in critical care outcomes specifically for patients with complications of decompensated cirrhosis.

Renal dysfunction is common in hospitalized patients with cirrhosis with prior studies finding that approximately 20% of patients with cirrhosis admitted to the hospital experience renal dysfunction, and up to 50% admitted to the ICU experience renal failure with 20–30% receiving RRT [11, 12, 38, 39]. Our findings are in-line with previous work as we found RRT was utilized more in hospitalizations for patients with cirrhosis compared to those without cirrhosis. RRT was used in 12.2% of hospitalizations for decompensated cirrhosis and mortality was significantly increased in those who required RRT (46.5% vs. 31.3%, p < 0.001). Renal failure has previously been identified as a risk factor for mortality in patients with cirrhosis [14, 18, 21, 23, 38]. Indeed, for non-transplant candidate patients with cirrhosis, inpatient mortality after initiating RRT has been estimated to be between 65 and 75% with 6-month mortality as high as 85% [39,40,41,42,43]. Our findings again suggest a decreased prevalence of RRT and mortality in those who receive it, but we are limited by the inability to follow-up patients after discharge. Additionally, we are unable to assess which patients went on to receive a transplant after discharge.

CPR outcomes in patients with cirrhosis have been shown to be worse than in patients with metastatic cancer with previous studies estimating in-hospital mortality rates from 85 to 90% [44,45,46]. Our study supports these previous findings with an in-hospital mortality rate of 88% which was significantly higher than the in-hospital mortality when cirrhosis was not present. Notably, our study found that outcomes were particularly poor in those with hepatorenal syndrome receiving CPR with 96% not surviving to discharge. Palliative care encounters were increased in hospitalizations for decompensated cirrhosis complications compared to hospitalizations for patients without cirrhosis in our study (21.4% vs. 14.5%, p < 0.001), but it is notable that the majority (78.6%) of those critically ill with complications of decompensated cirrhosis do not have a palliative care encounter. The poor CPR outcomes noted in this study further emphasize the need for honest discussions around prognosis, possibly with the assistance of a palliative care professional, to allow patients and families to make informed decisions about their code status.

Significant strengths of our study include the large, nationwide, generalizable sample and our reporting of outcomes stratified by primary admission diagnosis. Inclusion of patients who received a liver transplant during the index hospitalization improves the generalizability of our results. However, we limited our discussion of liver transplantation outcomes in this study as the NIS does not specify whether or not a patient was admitted to a liver transplant center or eventually referred to a transplant center. Other limitations include the reliance on ICD-10 codes, a lack of laboratory data and the inability to provide information on outcomes after hospital discharge which limits our conclusions largely to inpatient outcomes. The lack of laboratory data prevented us from including commonly used prognostic tools for both liver disease and critical care such as Model for End-Stage Liver Disease and Sequential Organ Failure Assessment scores and it limited the ability to fully assess the extent and number of organ failures in individual patients. However, we would note that a previous single center assessment of ICU mortality in patients with cirrhosis found MELD to be a relatively poor prognostic marker while factors such as the need for RRT and intubation, which were included in our study, were more predictive of mortality 41. Restricting our definition of critical care to those requiring intubation or a central venous catheter likely excluded many patients who did require ICU admission. Additionally, the inclusion of these procedures within the NIS is contingent upon documentation of them being performed and billing for the procedures and the NIS does not provide the indication for procedures. However, we believe that providing an operational definition of critical care which can be applied to future studies using administrative databases is a balancing strength and will allow for future trend analysis.

Conclusions

Critical care outcomes may be improving in patients with cirrhosis. The need for RRT may not be as poor of a prognostic marker as previously believed with 53% of those who required it surviving to discharge. CPR outcomes, on the other hand, remain poor with 88% in-hospital mortality. These findings aide in defining trends in critical care outcomes in patients with cirrhosis and can inform prognosis discussions with patients and families, particularly when discussing code status.

Availability of data and materials

The dataset supporting the conclusions of this article is available in the National Inpatient Sample repository, https://hcup-us.ahrq.gov/tech_assist/centdist.jsp.

Abbreviations

CPR:

Cardiopulmonary resuscitation

HCUP:

Healthcare cost and utilization project

ICD:

International classification of diseases

ICU:

Intensive care unit

NIS:

National inpatient sample

RRT:

Renal replacement therapy

SD:

Standard deviation

U.S.:

United States

References

  1. Garcia-Pagan JC, Francoz C, Montagnese S, et al. Management of the major complications of cirrhosis: beyond guidelines. J Hepatol. 2021;75(Suppl 1):S135–46. https://doi.org/10.1016/j.jhep.2021.01.027.

    Article  PubMed  Google Scholar 

  2. Passi NN, McPhail MJ. The patient with cirrhosis in the intensive care unit and the management of acute-on-chronic liver failure. J Intensive Care Soc. 2022;23(1):78–86. https://doi.org/10.1177/1751143720978849.

    Article  PubMed  Google Scholar 

  3. Patel AA, Ryan GW, Tisnado D, et al. Deficits in advance care planning for patients with decompensated cirrhosis at liver transplant centers. JAMA Intern Med. 2021;181(5):652–60. https://doi.org/10.1001/jamainternmed.2021.0152.

    Article  PubMed  PubMed Central  Google Scholar 

  4. Berry PA, Thomson SJ, Rahman TM, et al. Review article: towards a considered and ethical approach to organ support in critically-ill patients with cirrhosis. Aliment Pharmacol Ther. 2013;37(2):174–82. https://doi.org/10.1111/apt.12133.

    Article  CAS  PubMed  Google Scholar 

  5. Scaglione S, Kliethermes S, Cao G, et al. The epidemiology of cirrhosis in the united states: a population-based study. J Clin Gastroenterol. 2015;49(8):690–6. https://doi.org/10.1097/MCG.0000000000000208.

    Article  PubMed  Google Scholar 

  6. Moon AM, Singal AG, Tapper EB. Contemporary epidemiology of chronic liver disease and cirrhosis. Clin Gastroenterol Hepatol. 2020;18(12):2650–66. https://doi.org/10.1016/j.cgh.2019.07.060.

    Article  PubMed  Google Scholar 

  7. Garg SK, Goyal H, Obaitan I, et al. Incidence and predictors of 30-day hospital readmissions for liver cirrhosis: insights from the United States national readmissions database. Ann Transl Med. 2021;9(13):1052. https://doi.org/10.21037/atm-20-1762.

    Article  PubMed  PubMed Central  Google Scholar 

  8. McPhail MJW, Parrott F, Wendon JA, et al. Incidence and outcomes for patients with cirrhosis admitted to the United Kingdom critical care units. Crit Care Med. 2018;46(5):705–12. https://doi.org/10.1097/CCM.0000000000002961.

    Article  PubMed  PubMed Central  Google Scholar 

  9. Gines P, Fernandez J, Durand F, et al. Management of critically-ill cirrhotic patients. J Hepatol. 2012;56(Suppl 1):S13-24. https://doi.org/10.1016/S0168-8278(12)60003-8.

    Article  CAS  PubMed  Google Scholar 

  10. Ghabril M. Improving outcomes in critical care of patients with cirrhosis and organ failure: herding runaway horses and securing the barn door. Clin Gastroenterol Hepatol. 2015;13(7):1361–3. https://doi.org/10.1016/j.cgh.2015.02.004.

    Article  PubMed  Google Scholar 

  11. Biancofiore G, Auzinger G, Mandell S, et al. Liver cirrhosis in the medical critical care patient. Minerva Anestesiol. 2012;78(6):693–703.

    CAS  PubMed  Google Scholar 

  12. Katsounas A, Canbay A. Intensive care therapy for patients with advanced liver diseases. Visc Med. 2018;34(4):283–9. https://doi.org/10.1159/000492088.

    Article  PubMed  PubMed Central  Google Scholar 

  13. Chandna S, Zarate ER, Gallegos-Orozco JF. Management of decompensated cirrhosis and associated syndromes. Surg Clin North Am. 2022;102(1):117–37. https://doi.org/10.1016/j.suc.2021.09.005.

    Article  PubMed  Google Scholar 

  14. Kavli M, Strom T, Carlsson M, et al. The outcome of critical illness in decompensated alcoholic liver cirrhosis. Acta Anaesthesiol Scand. 2012;56(8):987–94. https://doi.org/10.1111/j.1399-6576.2012.02692.x.

    Article  CAS  PubMed  Google Scholar 

  15. Costa ESPP, Codes L, Rios FF, et al. Comparison of general and liver-specific prognostic scores in their ability to predict mortality in cirrhotic patients admitted to the intensive care unit. Can J Gastroenterol Hepatol. 2021;2021:9953106. https://doi.org/10.1155/2021/9953106.

    Article  Google Scholar 

  16. Moreau R, Hadengue A, Soupison T, et al. Septic shock in patients with cirrhosis: hemodynamic and metabolic characteristics and intensive care unit outcome. Crit Care Med. 1992;20(6):746–50. https://doi.org/10.1097/00003246-199206000-00008.

    Article  CAS  PubMed  Google Scholar 

  17. Sadick V, Bowcock E, Lane S, et al. Survival and predictors of outcome among patients with decompensated liver disease in a non-liver transplant intensive care unit. Pessimism is historical and unjustified. Intern Med J. 2019;49(6):745–52. https://doi.org/10.1111/imj.14151.

    Article  PubMed  Google Scholar 

  18. Cholongitas E, Calvaruso V, Senzolo M, et al. RIFLE classification as predictive factor of mortality in patients with cirrhosis admitted to intensive care unit. J Gastroenterol Hepatol. 2009;24(10):1639–47. https://doi.org/10.1111/j.1440-1746.2009.05908.x.

    Article  CAS  PubMed  Google Scholar 

  19. Thomson SJ, Moran C, Cowan ML, et al. Outcomes of critically ill patients with cirrhosis admitted to intensive care: an important perspective from the non-transplant setting. Aliment Pharmacol Ther. 2010;32(2):233–43. https://doi.org/10.1111/j.1365-2036.2010.04341.x.

    Article  CAS  PubMed  Google Scholar 

  20. Sasso R, Lauzon S, Rockey DC. Cirrhotic patients on mechanical ventilation have a low rate of successful extubation and survival. Dig Dis Sci. 2020;65(12):3744–52. https://doi.org/10.1007/s10620-020-06051-6.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  21. O’Brien AJ, Welch CA, Singer M, et al. Prevalence and outcome of cirrhosis patients admitted to UK intensive care: a comparison against dialysis-dependent chronic renal failure patients. Intensive Care Med. 2012;38(6):991–1000. https://doi.org/10.1007/s00134-012-2523-2.

    Article  PubMed  Google Scholar 

  22. Cartwright LA, Dumenci L, Siminoff LA, et al. Cancer patients’ understanding of prognostic information. J Cancer Educ. 2014;29(2):311–7. https://doi.org/10.1007/s13187-013-0603-9.

    Article  PubMed  PubMed Central  Google Scholar 

  23. Bal CK, Daman R, Bhatia V. Predictors of fifty days in-hospital mortality in decompensated cirrhosis patients with spontaneous bacterial peritonitis. World J Hepatol. 2016;8(12):566–72. https://doi.org/10.4254/wjh.v8.i12.566.

    Article  PubMed  PubMed Central  Google Scholar 

  24. Fichet J, Mercier E, Genee O, et al. Prognosis and 1-year mortality of intensive care unit patients with severe hepatic encephalopathy. J Crit Care. 2009;24(3):364–70. https://doi.org/10.1016/j.jcrc.2009.01.008.

    Article  CAS  PubMed  Google Scholar 

  25. Mishra SB, Misra R, Azim A, et al. Incidence, risk factors and associated mortality of central line-associated bloodstream infections at an intensive care unit in northern India. Int J Qual Health Care. 2017;29(1):63–7. https://doi.org/10.1093/intqhc/mzw144.

    Article  CAS  PubMed  Google Scholar 

  26. Fernandez-Zamora MD, Gordillo-Brenes A, Banderas-Bravo E, et al. Prolonged mechanical ventilation as a predictor of mortality after cardiac surgery. Respir Care. 2018;63(5):550–7. https://doi.org/10.4187/respcare.04915.

    Article  PubMed  Google Scholar 

  27. Walden AP, Clarke GM, McKechnie S, et al. Patients with community acquired pneumonia admitted to European intensive care units: an epidemiological survey of the GenOSept cohort. Crit Care. 2014;18(2):R58. https://doi.org/10.1186/cc13812.

    Article  PubMed  PubMed Central  Google Scholar 

  28. Majeed A, Majumdar A, Bailey M, et al. Declining mortality of cirrhotic variceal bleeding requiring admission to intensive care: a binational cohort study. Crit Care Med. 2019;47(10):1317–23. https://doi.org/10.1097/CCM.0000000000003902.

    Article  PubMed  Google Scholar 

  29. Majumdar A, Bailey M, Kemp WM, et al. Declining mortality in critically ill patients with cirrhosis in Australia and New Zealand between 2000 and 2015. J Hepatol. 2017;67(6):1185–93. https://doi.org/10.1016/j.jhep.2017.07.024.

    Article  PubMed  Google Scholar 

  30. Cheung K, Mailman JF, Crawford JJ, et al. Trends and outcomes of mechanically ventilated cirrhotic patients in the United States from 2005–2014. J Intensive Care Soc. 2022;23(2):139–49. https://doi.org/10.1177/1751143720985293.

    Article  PubMed  Google Scholar 

  31. Kumar R, Kerbert AJC, Sheikh MF, et al. Determinants of mortality in patients with cirrhosis and uncontrolled variceal bleeding. J Hepatol. 2021;74(1):66–79. https://doi.org/10.1016/j.jhep.2020.06.010.

    Article  PubMed  Google Scholar 

  32. Tapper EB, Parikh ND. Diagnosis and management of cirrhosis and its complications: a review. JAMA. 2023;329(18):1589–602. https://doi.org/10.1001/jama.2023.5997.

    Article  CAS  PubMed  Google Scholar 

  33. Zanetto A, Shalaby S, Feltracco P, et al. Recent advances in the management of acute variceal hemorrhage. J Clin Med. 2021. https://doi.org/10.3390/jcm10173818.

    Article  PubMed  PubMed Central  Google Scholar 

  34. Dong V, Karvellas CJ. Acute-on-chronic liver failure: objective admission and support criteria in the intensive care unit. JHEP Rep. 2019;1(1):44–52. https://doi.org/10.1016/j.jhepr.2019.02.005.

    Article  PubMed  PubMed Central  Google Scholar 

  35. Tonon M, Angeli P, Piano S. Bacterial infections in cirrhosis. Infect Microbes Dis. 2021;3(3):117–24. https://doi.org/10.1097/im9.0000000000000065.

    Article  CAS  Google Scholar 

  36. Thalheimer U, Triantos CK, Samonakis DN, et al. Infection, coagulation, and variceal bleeding in cirrhosis. Gut. 2005;54(4):556–63. https://doi.org/10.1136/gut.2004.048181.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

  37. Merli M, Riggio O. Interaction between infection and hepatic encephalopathy. J Hepatol. 2015;62(3):746–7. https://doi.org/10.1016/j.jhep.2014.10.028.

    Article  PubMed  Google Scholar 

  38. Carvalho GC, Regis Cde A, Kalil JR, et al. Causes of renal failure in patients with decompensated cirrhosis and its impact in hospital mortality. Ann Hepatol. 2012;11(1):90–5.

    Article  PubMed  Google Scholar 

  39. Del Risco-Zevallos J, Andujar AM, Pineiro G, et al. Management of acute renal replacement therapy in critically ill cirrhotic patients. Clin Kidney J. 2022;15(6):1060–70. https://doi.org/10.1093/ckj/sfac025.

    Article  PubMed  PubMed Central  Google Scholar 

  40. Witzke O, Baumann M, Patschan D, et al. Which patients benefit from hemodialysis therapy in hepatorenal syndrome? J Gastroenterol Hepatol. 2004;19(12):1369–73. https://doi.org/10.1111/j.1440-1746.2004.03471.x.

    Article  PubMed  Google Scholar 

  41. Annamalai A, Harada MY, Chen M, et al. Predictors of mortality in the critically ill cirrhotic patient: Is the model for end-stage liver disease enough? J Am Coll Surg. 2017;224(3):276–82. https://doi.org/10.1016/j.jamcollsurg.2016.11.005.

    Article  PubMed  Google Scholar 

  42. Allegretti AS, Ortiz G, Wenger J, et al. Prognosis of acute kidney injury and hepatorenal syndrome in patients with cirrhosis: a prospective cohort study. Int J Nephrol. 2015;2015:108139. https://doi.org/10.1155/2015/108139.

    Article  PubMed  PubMed Central  Google Scholar 

  43. Wong LP, Blackley MP, Andreoni KA, et al. Survival of liver transplant candidates with acute renal failure receiving renal replacement therapy. Kidney Int. 2005;68(1):362–70. https://doi.org/10.1111/j.1523-1755.2005.00408.x.

    Article  PubMed  Google Scholar 

  44. Ufere NN, Brahmania M, Sey M, et al. Outcomes of in-hospital cardiopulmonary resuscitation for patients with end-stage liver disease. Liver Int. 2019;39(7):1256–62. https://doi.org/10.1111/liv.14079.

    Article  PubMed  Google Scholar 

  45. Roedl K, Wallmuller C, Drolz A, et al. Outcome of in- and out-of-hospital cardiac arrest survivors with liver cirrhosis. Ann Intensive Care. 2017;7(1):103. https://doi.org/10.1186/s13613-017-0322-1.

    Article  PubMed  PubMed Central  Google Scholar 

  46. Oud L. In-hospital cardiopulmonary resuscitation of patients with cirrhosis: a population-based analysis. PLoS ONE. 2019;14(9):e0222873. https://doi.org/10.1371/journal.pone.0222873.

    Article  CAS  PubMed  PubMed Central  Google Scholar 

Download references

Acknowledgements

Not applicable.

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or non-for-profit sectors.

Author information

Authors and Affiliations

  1. Department of Medicine, Hennepin Healthcare, 730 South 8th Street, Minneapolis, MN, 55415, USA

    Spencer R. Goble

  2. Department of Internal Medicine, University of Maryland Medical Center Midtown Campus, 827 Linden Ave, Baltimore, MD, 21201, USA

    Abdellatif S. Ismail

  3. Department of Medicine, University of Minnesota, Mayo Memorial Building, MMC 250, 420 Delaware Street S.E., Minneapolis, MN, 55455, USA

    Jose D. Debes

  4. Division of Gastroenterology, Hepatology, and Nutrition, University of Minnesota, MMC 36, 420 Delaware Street S.E., Minneapolis, MN, 55455, USA

    Thomas M. Leventhal

Authors
  1. Spencer R. Goble
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Abdellatif S. Ismail
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Jose D. Debes
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Thomas M. Leventhal
    View author publications

    You can also search for this author in PubMed Google Scholar

Contributions

SG, JD, and TL contributed to the design of the study. SG performed data analysis. SG, AI, JD, and TL contributed to interpretation of the data. SG drafted the initial version of the manuscript. SG, AI, JD, and TL provided critical review and editing of the manuscript. JD and TL provided supervision for the project.

Corresponding author

Correspondence to Spencer R. Goble.

Ethics declarations

Ethics approval and consent to participate

Deidentified, publicly available data was used in this project and ethical approval was therefore waived.

Consent for publication

Not applicable.

Competing interests

The authors declare that they have no competing interests.

Additional information

Publisher's Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Supplementary Information

Rights and permissions

Open Access This article is licensed under a Creative Commons Attribution 4.0 International License, which permits use, sharing, adaptation, distribution and reproduction in any medium or format, as long as you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons licence, and indicate if changes were made. The images or other third party material in this article are included in the article's Creative Commons licence, unless indicated otherwise in a credit line to the material. If material is not included in the article's Creative Commons licence and your intended use is not permitted by statutory regulation or exceeds the permitted use, you will need to obtain permission directly from the copyright holder. To view a copy of this licence, visit http://creativecommons.org/licenses/by/4.0/. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated in a credit line to the data.

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Goble, S.R., Ismail, A.S., Debes, J.D. et al. Critical care outcomes in decompensated cirrhosis: a United States national inpatient sample cross-sectional study. Crit Care 28, 150 (2024). https://doi.org/10.1186/s13054-024-04938-8

Download citation

  • Received:

  • Accepted:

  • Published:

  • DOI: https://doi.org/10.1186/s13054-024-04938-8

Keywords

Critical Care

ISSN: 1364-8535