Associations Between Mean Arterial Pressure Thresholds and Clinical Outcomes in Decompensated Cirrhosis With Septic...

Short-term mortality remains high in decompensated cirrhosis patients with septic shock. While a mean arterial pressure (MAP) >65 mm Hg is recommended for the management of septic shock in the general population, the optimal MAP for decompensated cirrhosis is not well defined. We evaluated the association between various MAP thresholds, 28-day mortality, and acute kidney injury (AKI) nonrecovery.

We conducted a multicenter retrospective analysis of decompensated cirrhosis patients with septic shock admitted to intensive care units across 20 Texas hospitals (January 1, 2014-December 31, 2022). Time weighted average MAP (TWA-MAP) during the initial 72 hours of admission was calculated to quantify hypotension exposure. Multivariable logistic regression models assessed the impact of various TWA-MAP thresholds (60-90 mm Hg) on 28-day mortality and AKI nonrecovery, adjusting for relevant confounders.

Among 1,145 patients (mean age 64, Model for End-Stage Liver Disease 26, 43% female, 19% non-White, 22% Hispanic, 38% alcohol-associated cirrhosis), 66% had AKI, with 37% nonrecovery; 28-day mortality was 56%. Increasing TWA-MAP from <60 mm Hg to 75 mm Hg was associated with a stepwise reduction in the odds of 28-day mortality (<60 odds ratio [OR] 2.775; <65 OR 1.607; <70 OR 1.305; <75 OR 1.180). However, the survival benefit plateaued >75 mm Hg. Similar associations were found for AKI nonrecovery (<60 1.151; <65 OR 1.153; <70 OR 1.110; <75 OR 1.079) and reductions attenuated >75 mm Hg.

Maintaining MAP between 70 and 75 mm Hg may optimize survival and kidney recovery in patients with decompensated cirrhosis and septic shock. Randomized trials are needed to compare traditional MAP targets (60-65 mm Hg) with intermediate targets (70-75 mm Hg) to improve outcomes in this high-risk population.