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Critical Care  2013 

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

DOI: 10.1186/cc12508

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Abstract:

Multi-center retrospective cohort study consisting of two datasets: 1) all critically-ill cirrhotic patients requiring intensive care unit (ICU) admission prior to LT at five transplant centers in Canada from 2000-2009 (one site 1990-2009) and 2) critically ill cirrhotics receiving LT from ICU (n=115) and those listed but not receiving LT prior to death (n=106) from two centres where complete data was available.In the first dataset, 198 critically ill cirrhotics 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, 1.01-1.14, p=0.013). SOFA score did not predict 90-day mortality at any time-point. In the second dataset, 47.9% (n=106) of cirrhotics listed for LT died in 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, 0.82-0.97, 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; 0.17-0.61, p=0.001).SOFA appears poor at predicting 90-day survival in critically ill cirrhotics following LT, but higher SOFA score and elevated lactate 48 hours after ICU admission are associated with a lower probability receiving LT. Older critically ill cirrhotics (over 60) receiving LT have worse 90-day survival and should be considered for LT with caution.

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