Effect of end-stage liver failure on the incidence and resolution of the adult respiratory distress syndrome

Multiple systems organ failure adversely affects outcome in the adult respiratory distress syndrome (ARDS). However, no clinical studies of the influence of preexisting single extrapulmonary organ dysfunction on the incidence and resolution of ARDS have been reported. Hepatic reticuloendothelial system (RES) and hepatic parenchymal cell uptake and detoxification of proinflammatory substances are major elements of systemic host defense and may, accordingly, be important pulmonary defense mechanisms. To better define the effects of liver-lung interactions on the resolution of acute lung injury with preexisting extreme hepatic dysfunction, we retrospectively analyzed the incidence, risk factors, and clinical characteristics of ARDS in 29 patients with end-stage liver failure (ESLF) who required intensive care while awaiting a liver transplantation. We compared data from these patients with those from a concurrent group of 44 intensive care patients without ESLF, and contrasted our findings with recent clinical studies of ARDS predisposition and outcome. ARDS occurred in 23 of 29 patients (79%) with ESLF; sepsis was the most common predisposing risk factor (18 of 29 patients, 62%). ARDS developed in 3 of 44 patients (6.8%) without ESLF (odds ratio comparison with ESLF patients, 42.9, P < .001). Once initiated, regardless of etiology and subsequent ventilatory support, ARDS was uniformly irreversible in all 23 ESLF patients. These findings identify a growing population of critically ill patients at increased risk for nonresolving severe acute lung injury despite current methods of intensive care. We conclude that compromise of systemic and pulmonary defense by impaired hepatic RES performance and hepatocyte function may both predispose to ARDS and critically modulate its resolution.