Cirrhosis and Outcomes in Acute Respiratory Distress Syndrome: A Systematic Review and Prognostic Meta-Analysis

Document Type

Conference Proceeding

Publication Date

5-2026

Publication Title

American Journal of Respiratory and Critical Care Medicine

Abstract

Rationale: Acute respiratory distress syndrome (ARDS) is a prevalent condition in medical intensive care units (ICU) with hospital mortality ranging from 35 to 46%. Previous studies have suggested worse outcomes in cirrhotic compared with non-cirrhotic (NC) patients with ARDS; however, this association has been reexamined considering recent advances in ARDS management. No meta-analysis has evaluated this association, and cirrhotic patients remain excluded from most randomized controlled trials. Our study aims to assess the impact of cirrhosis among patients with ARDS. Methods: We reviewed PubMed, Embase, and Cochrane Central for studies evaluating cirrhotic and NC patients with ARDS. The main outcomes were in-hospital, 28/30-day, and 90-day mortality. Statistical analysis was performed using Review Manager (Cochrane Collaboration) and R Studio. Heterogeneity was examined with Cochran Q test and I (2) statistics; p values inferior to 0.10 and I (2) >25% were considered significant for heterogeneity. For studies before 2012, we accepted the definition of acute lung injury from the American European Consensus Conference, as most patients classified as ARDS under this definition currently correspond to moderate-to-severe ARDS under Berlin criteria. Results: Ten studies comprising 13.491 patients met inclusion criteria. Two studies originated from the same institution with overlapping enrollment periods; to avoid duplication, one was excluded from the overall mortality analysis, but both were retained for sensitivity assessments. Overall, 787 patients (5.8%) had cirrhosis. Mechanical ventilation (MV) was required in 97.7% of patients, and four studies explicitly reported using lung-protective strategies. Crude hospital mortality among cirrhotic patients decreased from 81% before 2000 to 71% after 2000, compared with 61.2% and 14.8% in NC patients, though the study with the largest sample after 2000 included < 1% cirrhotics. At 28/30 days, mortality was significantly higher in cirrhotic patients (RR 1.40; 95% CI 1.26-1.54; p < 0.00001; I2 = 0%). Sensitivity analysis including adjusted estimates (two studies) was not statistically significant (adjusted HR 1.77; 95% CI 0.7-4.45; p = 0.23; I2 = 94%). In multivariate analysis, in-hospital mortality remained higher in cirrhotics (adjusted OR 6.98; 95% CI 3.82-12.75; p < 0.00001; I2 =0%). Ninety-day mortality (two studies) was also greater among cirrhotic patients (adjusted HR 1.67; 95% CI 1.31-2.11; p < 0.0001; I2 = 3%). Conclusions: Cirrhosis is associated with increased mortality in ARDS patients, though adjusted short-term analyses yielded heterogeneous results. Given the limited sample size and underrepresentation of cirrhotic patients in recent ARDS trials, further high-quality studies are necessary to clarify this association.

Volume

212

Issue

S1

First Page

S80

Comments

American Thoracic Society International Conference, May 15-20, 2026, Orlando, FL

Last Page

S81

DOI

10.1093/ajrccm/aamag162.109

Link to Full Text

Share

COinS