PURPOSE: Critically-ill patients with end-stage liver disease (ESLD) are at high risk of dying during intensive care unit (ICU) hospitalization. Currently available prognostic models assume no role of gender in predicting mortality. We aimed to explore health outcomes among critically-ill ESLD patients based on demographics, clinical parameters, and existing prognostic models.
METHODS: Retrospective review of 916 ICU admissions for patients with a history of ESLD who did not undergo liver transplant at a public hospital serving a primarily indigent, Hispanic population in Los Angeles, CA. The main outcome measure was in-hospital mortality.
RESULTS: The study population was predominantly male (76%) and Hispanic (76%), with mean Mayo End-stage Liver Disease (MELD) score of 27 and mean Acute Physiology and Chronic Health Evaluation (APACHE) II score of 25. Median age was 50 years, and alcohol use was reported in 60%. For men and women, in-hospital mortality rates were 35% and 43% (p=0.02), respectively, despite similar MELD score (27 vs 27, p=0.73), APACHE II score (26 vs 26, p=0.63), and rates of mechanical ventilation (74% vs 75%, p=0.73), gastrointestinal bleed (6% vs 7%, p=0.44), and sepsis (27% and 25%, p=0.60). After multivariate adjustment, female gender was strongly associated with death (odds ratio [OR] 1.61; 95% CI 1.01 - 2.61); there was also a statistically significant interaction between MELD score and gender (p=0.01). A gender-specific analysis showed higher odds ratio of death for MELD per 1-point increase in men (OR 1.14; 95% 1.11 - 1.17) than in women (OR 1.07; 95% CI 1.02 - 1.11), while APACHE II score had a lower association with death per 1-point increase in men (OR 1.03; 95% CI 1.00 - 1.06) than in women (OR 1.07; 95% CI 1.02 - 1.12). Mechanical ventilation had over two-fold higher association of death in women (OR 8.23; 95% CI 1.00 - 68.01) than in men (OR 3.68; 95% CI 1.56 - 8.72).
CONCLUSIONS: In critically-ill patients with ESLD, women appear to have higher mortality despite similar MELD score, APACHE II score, and rates of mechanical ventilation. This difference is more pronounced at lower MELD scores and appears to be associated with mechanical ventilation. Further studies are needed to confirm these disparities in non-minority populations.
CLINICAL IMPLICATIONS: Critically-ill, mechanically ventilated female patients should undergo closer monitoring and perhaps receive higher priority for organ transplants.
DISCLOSURE: The following authors have nothing to disclose: Alex Balekian, Michael Gould
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