Comparative Outcomes of Patients With Alcohol-Associated and Non-Alcohol-Associated Cirrhosis With Acute Infections in the Medical Intensive Liver Unit

Introduction: Alcohol-associated liver disease is associated with hepatic inflammation and uniquely predisposes patients to infections and associated acute-on-chronic liver failure (ACLF). Alcohol use is among the leading causes of ACLF and associated mortality in the critical care setting. We aimed to compare baseline characteristics and outcomes of infections in patients with alcohol-associated cirrhosis (ALD) and non-alcohol associated cirrhosis (NALD) in the Medical Intensive Liver Unit (MILU). Methods: From our prospective registry of patients admitted to our MILU between August 2018-September 2022, we identified 80 culture-positive patients with ALD and 82 with NALD. Chi-squared and t-tests were used to compare the 2 groups on comorbidities, acute characteristics of infection, and clinical outcomes. Results: Compared to NALD patients, patients with ALD were younger (56 years vs 61 years, P = 0.003) and had higher rates of pre-infection ascites and hepatic encephalopathy (98% vs 88%, P = 0.018; 95% vs 82%, P = 0.009 respectively) (Table 1). The majority of infections were bacterial (87%) (Enterococcus faecium, Escherichia coli, and Klebsiella spp) followed by fungal (13%) (Candida). Rates of fungal infections and multi-drug resistant (MDR) infections were similar between patient groups. At time of infection, bilirubin (13.88 vs 8.58, P = 0.003), MELD-Na (31.62 vs 27.92, P = 0.006) and Child Pugh scores (11.39 vs 10.70, P = 0.012) were significantly higher in ALD patients; degree of ACLF severity was similar between patient groups. ALD patients more frequently required intubation (81% vs 62%, P = 0.007), but had similar rates of vasopressor requirements, ICU, and hospital LOS. Rates of listing for liver transplant (LT) were lower in ALD patients (43% vs 63%, P = 0.039), while rates of LT among listed patients and in-hospital mortality were similar. The 2 groups did not differ in survival (Figure 1). Conclusion: Critically ill ALD patients are younger with higher markers of liver disease severity at time of acute infection but have similar rates of organ failure or ACLF grade, and comparable outcomes of mortality, LOS, MDR infection, ACLF severity, and rates of LT as NALD patients in the critical setting following infection. Future studies elucidating the impact of ALD severity and active alcohol use on predisposition to infection and ACLF-related outcomes are needed. Table 1. - Comparison of Baseline Characteristics, Acute Infections, and Outcomes Between Patients with Alcohol and Non-Alcohol Associated Cirrhosis Non-Alcohol Associated Cirrhosis Alcohol-Associated Cirrhosis P-value N = 82 N = 80 Age 61 (10) 56 (11) 0.003 Sex 44 (54%) 51 (64%) 0.19 Race 0.54 White 63 (77%) 60 (75%) American Indian/Alaska Native 1 (1%) 0 (0%) Asian 1 (1%) 0 (0%) Black 9 (11%) 15 (19%) Declined 1 (1%) 0 (0%) Multiracial/cultural 2 (2%) 2 (3%) Unavailable 5 (6%) 3 (4%) Charlson Comorbidity Score 5 (4-7) 6 (5-8) 0.15 Hepatocellular carcinoma 12 (15%) 5 (6%) 0.082 Decompensation-Defining Complications Pre-Infection Ascites 72 (88%) 78 (98%) 0.018 Hepatic encephalopathy 67 (82%) 76 (95%) 0.009 Hepatorenal syndrome 32 (39%) 41 (51%) 0.12 EV history/Variceal bleeding 57 (70%) 61 (76%) 0.34 Hepatopulmonary syndrome 2 (2%) 0 (0%) 0.16 Porto-pulmonary hypertension 3 (4%) 3 (4%) 0.98 Hepatic hydrothorax 14 (17%) 16 (20%) 0.63 SBP 27 (33%) 30 (38%) 0.54 Coagulopathy 59 (72%) 62 (78%) 0.42 Thrombocytopenia 62 (76%) 59 (74%) 0.79 Characteristics on Day of Infection Infectious micro-organism 0.22 Bacterial 74 (90%) 67 (84%) Fungal 8 (10%) 13 (16%) Creatinine 2.523 (1.89) 2.26 (1.39) 0.31 INR 1.94 (.81) 2.22 (1.08) 0.068 Bilirubin 8.58 (10.87) 13.88 (11.70) 0.003 Child-Pugh score 10.70 (1.77) 11.39 (1.73) 0.012 MELD-Na 27.93 (7.65) 31.62 (9.11) 0.006 MDRO 33 (40%) 38 (48%) 0.35 ACLF grade 0.79 0 12 (15%) 9 (11%) 1 16 (20%) 15 (19%) 2-3 54 (66%) 56 (70%) Comparison of Outcomes Death during admission or hospice 51 (62%) 53 (66%) 0.59 Vasopressor required 4 (31%) 4 (33%) 0.89 Mechanical ventilation 51 (62%) 65 (81%) 0.007 Reason for intubation 0.082 Airway protection 14 (27%) 28 (43%) Respiratory failure 37 (73%) 37 (57%) ICU Length of stay (days) 5 (2-9) 5 (2-10.5) 0.54 Hospital length of stay (days) 15 (7-25) 17 (9-32.5) 0.072 ICU to Hosp Admit (days) 1 (0-10) 1 (0-11.5) 0.60 Evaluated for transplant 51 (62%) 54 (68%) 0.48 Listed 32 (63%) 23 (43%) 0.039 Organ listed 0.49 Liver 22 (71%) 19 (79%) Liver and kidney 9 (29%) 5 (21%) Hold placed 21 (66%) 11 (48%) 0.19 Transplant occurred 13 (16%) 13 (16%) 0.95 Figure 1.: Comparison of Survival Between Patients With ALD and non-ALD Cirrhosis With Infections.