Prognosis of cirrhotic patients admitted to intensive care unit: a meta-analysis
Prognosis of cirrhotic patients admitted to intensive care unit: a meta-analysis
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DOI：
10.1186/s13613-017-0249-6
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发表时间：
2017-03-21
影响因子：
8.1
通讯作者：
Di Martino, Vincent
中科院分区：
文献类型：
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作者：
Weil, Delphine;Levesque, Eric;Di Martino, Vincent
背景：接受重症监护支持的肝硬化患者短期和中期死亡率的最佳预测因素尚不清楚。方法：在选择原始文章并回答相应作者的标准化问卷后，我们对 13 项研究（2523 名肝硬化患者）进行了荟萃分析。终点为 ICU 内、院内和 ICU 幸存者的 6 个月死亡率。总共进行了 301 项汇总分析，其中包括 95 项仅限于 ICU 幸存者 6 个月死亡率的分析，考虑了 249 个变量（包括入院原因、器官替代治疗和综合预后评分）。结果：ICU 内死亡率、院内死亡率和 6 个月死亡率分别为 42.7%、54.1% 和 75.1%。随访期间，48 名患者（3.8%）接受了肝移植。因静脉曲张出血入院的患者的 ICU 死亡率较低（OR 0.46；95% CI 0.36-0.59；p < 0.001），基线时 SOFA > 19 的患者死亡率较高（OR 8.54；95% CI 2.09-34.91；p < 0.001；PPV = 0.93）。高 SOFA 不再预测 ICU 幸存者 6 个月时的死亡率。与感染相关的 12 个变量是 ICU 死亡率的预测因子，包括 SIRS（OR 2.44；95% CI 1.64-3.65；p < 0.001；PPV = 0.57）、肺炎（OR 2.18；95% CI 1.47-3.22；p < 0.001；PPV = 0.69）、脓毒症相关难治性疾病少尿（OR 10.61；95% CI 4.07-27.63；p < 0.001；PPV = 0.76）和真菌感染（OR 4.38；95% CI 1.11-17.24；p < 0.001；PPV = 0.85）。在治疗方法中，仅使用多巴胺（OR 5.57；95% CI 3.02-10.27；p < 0.001；PPV = 0.68）、多巴酚丁胺（OR 8.92；95% CI 3.32-23.96；p < 0.001；PPV = 0.86）、肾上腺素（OR 5.03；95% CI 2.68-9.42；p < 0.001；PPV = 0.77）和 MARS（OR 2.07；95% CI 1.22-3.53；p = 0.007；PPV = 0.58）与 ICU 死亡率相关，无异质性。在 ICU 幸存者中，肝肾衰竭的 8 项标志物预测 6 个月死亡率，包括 Child-Pugh C 期（OR 2.43；95% CI 1.44-4.10；p < 0.001；PPV = 0.57）、基线 MELD > 26（OR 3.97；95% CI 1.92-8.22；p < 0.0001；PPV = 0.75）和肝肾综合征（OR 4.67；95% CI 1.24-17.64；p = 0.022；PPV = 0.88）。结论：入住 ICU 的肝硬化患者预后较差，因为只有少数患者接受了肝移植。与 Child-Pugh 和 MELD 评分不同，即使在器官衰竭的情况下记录，一般 ICU 评分的预后表现也会随着时间的推移而下降。感染相关参数具有短期影响，而肝肾衰竭对死亡率具有持续影响。
Background: The best predictors of short-and medium-term mortality of cirrhotic patients receiving intensive care support are unknown.Methods: We conducted meta-analyses from 13 studies (2523 cirrhotics) after selection of original articles and response to a standardized questionnaire by the corresponding authors. End-points were in-ICU, in-hospital, and 6-month mortality in ICU survivors. A total of 301 pooled analyses, including 95 analyses restricted to 6-month mortality among ICU survivors, were conducted considering 249 variables (including reason for admission, organ replacement therapy, and composite prognostic scores).Results: In-ICU, in-hospital, and 6-month mortality was 42.7, 54.1, and 75.1%, respectively. Forty-eight patients (3.8%) underwent liver transplantation during follow-up. In-ICU mortality was lower in patients admitted for variceal bleeding (OR 0.46; 95% CI 0.36-0.59; p < 0.001) and higher in patients with SOFA > 19 at baseline (OR 8.54; 95% CI 2.09-34.91; p < 0.001; PPV = 0.93). High SOFA no longer predicted mortality at 6 months in ICU survivors. Twelve variables related to infection were predictors of in-ICU mortality, including SIRS (OR 2.44; 95% CI 1.64-3.65; p < 0.001; PPV = 0.57), pneumonia (OR 2.18; 95% CI 1.47-3.22; p < 0.001; PPV = 0.69), sepsis-associated refractory oliguria (OR 10.61; 95% CI 4.07-27.63; p < 0.001; PPV = 0.76), and fungal infection (OR 4.38; 95% CI 1.11-17.24; p < 0.001; PPV = 0.85). Among therapeutics, only dopamine (OR 5.57; 95% CI 3.02-10.27; p < 0.001; PPV = 0.68), dobutamine (OR 8.92; 95% CI 3.32-23.96; p < 0.001; PPV = 0.86), epinephrine (OR 5.03; 95% CI 2.68-9.42; p < 0.001; PPV = 0.77), and MARS (OR 2.07; 95% CI 1.22-3.53; p = 0.007; PPV = 0.58) were associated with in-ICU mortality without heterogeneity. In ICU survivors, eight markers of liver and renal failure predicted 6-month mortality, including Child-Pugh stage C (OR 2.43; 95% CI 1.44-4.10; p < 0.001; PPV = 0.57), baseline MELD > 26 (OR 3.97; 95% CI 1.92-8.22; p < 0.0001; PPV = 0.75), and hepatorenal syndrome (OR 4.67; 95% CI 1.24-17.64; p = 0.022; PPV = 0.88).Conclusions: Prognosis of cirrhotic patients admitted to ICU is poor since only a minority undergo liver transplant. The prognostic performance of general ICU scores decreases over time, unlike the Child-Pugh and MELD scores, even recorded in the context of organ failure. Infection-related parameters had a short-term impact, whereas liver and renal failure had a sustained impact on mortality.