MELD-Lactate and lactate clearance in critically ill cirrhosis patients with sepsis.

OBJECTIVES MELD-lactate (MELD-LA) score is an independent predictor of inpatient mortality and organ failure validated in over 8,600 patients across diverse settings. However, its utility in sepsis, particularly when combined with lactate clearance (LA clearance), has not been fully evaluated. In this study, we examined the dynamic role of MELD-LA with 24-hour LA clearance as a predictor of 30-day mortality in critically ill patients with cirrhosis and sepsis.

METHODS We analyzed cirrhosis patients with sepsis admitted to the ICU in a large U.S. healthcare system (20 hospitals) from 2014-2022, examining MELD-LA and LA clearance within 24 hours as predictors of 30-day mortality. We externally validated our findings in the APASL-ACLF Research Consortium, a multinational Asian cohort (31 centers) from 2009-2019.

RESULTS A total of 3,879 cirrhosis patients with sepsis were admitted to the ICU (43.2% female, 20.5% Hispanic, 12.4% on dialysis; mean initial LA 4.5 mmol/L, MELD 20.8, MELD-LA 17.6). Survivors showed a median lactate change of -1.04 (35% clearance) compared to -0.4 (12%) for non-survivors. LA clearance within 24 hours was influenced by the presenting MELD-LA. In the North American cohort, ≥35% LA clearance was associated with improved 30-day survival (OR 0.41, 95% CI 0.31-0.53; p<0.001). Similarly, in the APASL cohort (n=1,259), ≥35% clearance was linked to a 60% reduction in mortality (OR 0.42, 95% CI 0.28-0.62; p<0.001). When stratified by LA clearance, patients with LA clearance of ≥35% had a higher percentage of early administration of resuscitative measures than those with LA clearance of < 10% especially with regards to early antibiotic administration (82.5% vs 67.6%; p-value <0.001).

CONCLUSION Early reduction in initial LA by one-third predicts 30-day mortality and may indicate treatment response in cirrhosis patients with sepsis in the ICU. Combining MELD-LA and LA clearance early enables better risk stratification and informs management.