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Caring for the Critically Ill Alcoholic Liver Disease Patient

An Uphill Battle Worth Fighting*

Flynn, Mary M., MD; Subramanian, Ram M., MD

doi: 10.1097/CCM.0000000000003488
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Department of Medicine, Emory University School of Medicine, Atlanta, GA

Departments of Medicine and Surgery, Emory University School of Medicine, Atlanta, GA

*See also p. 23.

The authors have disclosed that they do not have any potential conflicts of interest.

Alcoholic liver disease (ALD) is one of the main causes of liver disease worldwide (1). In contrast to strides made in the treatment of viral hepatitis, we have made little improvement in the pharmacologic options for management of ALD. Given its high prevalence and resultant heavy economic burden, there is increasing interest in this disease process. That interest has led to several studies demonstrating increased mortality in patients with ALD admitted to the ICU.

A retrospective study of 62 patients with ALD admitted to an ICU in Ireland demonstrated a poor in-hospital survival rate of 30.7% and a 6-month survival of 29% (2). Similarly, a retrospective study of 82 patients admitted to an ICU in the United Kingdom demonstrated a 67% in-hospital mortality (3). A population-based study in a Danish cohort of 1951 patients with acute alcoholic hepatitis demonstrated 21% mortality at 3 months, with the majority of deaths secondary to a liver-related event (4).

In this issue of Critical Care Medicine, Lone et al (5) present a large population-based cohort study that further highlights the increased mortality, as well as resource utilization, among this population. During the period of 2005 to 2010, patients with ALD admitted to the ICU suffered a 58.8% in-hospital mortality with a 5-year mortality of 79.2%. This was significantly higher than a comparator group consisting of non-ALD patients with severe comorbidities, as well as a cohort of non-ALD patients matched on multiple factors. Patients with ALD had a 32% and 17% higher 5-year readmission compared with the severe comorbid cohort and general ICU cohort, respectively. Roughly, half of the costs associated with readmission in the first several years were due to liver disease or alcohol-related issues. Of note, liver Sequential Organ Failure Assessment (SOFA) score was found to be an independent predictor of early and late mortality while the strongest predictor of readmission was the number of admissions during the year prior.

Lone et al (5) should be commended for clearly demonstrating poor short- and long-term survival in patients with ALD. However, critical knowledge gaps in the field remain. Namely, the study by Lone et al (5) does not address the factors influencing these poor outcomes nor address our ability to intervene on them.

The study by Lone et al (5) highlights that patients with ALD represent a high-risk population with poor overall outcomes. The mortality rate is appreciably high; thus, risk stratification in this population is of importance. There are several validated scoring systems to assist in risk stratification for hospitalized patients, such as the SOFA score or the Model for End-Stage Liver Disease score, both of which have been independently associated with mortality in cirrhotic patients admitted to the ICU (6 , 7). Similarly, Maddrey’s discriminant function and the Lille model can be used to predict severity of illness and outcomes in acute alcoholic hepatitis (8). Although there are growing data showing improved survival in patients with cirrhosis admitted to the ICU (9), we have not seen the same trend in ALD.

Data from other critically ill populations support the need for early aggressive care (9). However, we remain challenged in our pharmacologic management options for acute alcoholic hepatitis. Interestingly, the role of liver transplant for acute alcoholic decompensated liver disease is evolving, with an increasing number of centers offering transplant for acute alcoholic hepatitis in the United States and Europe. Initial analyses of posttransplant outcomes in this setting indicate favorable short-term and long-term trends, with a posttransplant alcohol relapse rate of 25% (10). Given the significant shortage of donor organs relative to the number of cirrhotic patients awaiting transplant, acute alcoholic hepatitis will continue to remain a highly controversial indication for transplant.

In the context of nontransplant management, among those who survive their hospital course, there is a high readmission rate resulting in a substantial economic burden in caring for these patients. Readmission rates are highest in the first year, with half of these related to liver disease or alcohol. As abstinence is the only independent predictor of long-term survival (11 , 12), the key is early intervention (both with identification of disease and management of the critically ill patient). Unfortunately, the majority of patients present to the hospital after they have already developed cirrhosis and mortality is higher in this population (4 , 11). It is critical to identify these patients early in their disease course and focus our efforts on novel strategies to improve abstinence. Similarly, in those hospitalized for ALD, resources need to be used to focus on intensive alcohol rehabilitation.

To conclude, ALD is a highly prevalent disease with poor outcomes. We stress the need for better resource utilization in achieving alcohol abstinence. In the critical care setting, short-term mortality is markedly high, and we urge providers to consider early aggressive care, with the understanding that we are currently limited in management options specific to acute ALD. The role of liver transplant in acute ALD is evolving, and its increasing application will influence the outcomes of this disease process favorably.

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REFERENCES

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Keywords:

alcoholic liver disease; outcomes

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