Critical Care Medicine

Medical Intensive Liver Unit

Cleveland Clinic's Medical Intensive Liver Unit (MILU), a collaboration of critical care and hepatology, opened in the summer of 2018. One of only a few liver-specific intensive care units in the US, it provides multidisciplinary care for critically ill patients with liver failure. Patients cared for in the MILU have acute liver failure, acute-on-chronic liver failure, and decompensated cirrhosis and its complications. Critically ill patients waiting or being evaluated for liver transplants receive care in the MILU from a multidisciplinary team that includes specialists in critical care, hepatology, surgery, anesthesia, social work, pharmacology, nursing, nutrition, and physical therapy. In 2023, 376 patients were admitted to MILU. While in the MILU, 128 of these patients were evaluated for liver transplants. Out of those 128 patients, 64 (50%) were listed, and 61 (47.7%) received a liver transplant during their hospital stay, with 25 (19.5%) going to the operating room directly from the MILU.

The MILU care team strives to provide optimal medical management of these patients with complex conditions. Whether optimizing their status in preparation for a transplant, returning them to home, or having timely, compassionate goals of care conversations, the MILU metrics reflect excellent care.

Podcasts

Cleveland Clinic Respiratory Medicine hosts podcasts series available on all major platforms including Apple, Google, Soundcloud and Spotify. Click on a link below to listen to the following podcast:

‘Medical Intensive Liver Unit: An ICU for Advanced Liver Disease Patients’ hosted by Raed Dweik, MD, MBA, Institute Chief and Chair, Pulmonary & Critical Care Medicine with guest Aanchal Kapoor, MD, MEd, Director, Medical Intensive Liver Unit (MILU).

MILU APACHE III Score

2021 – 2023

ᵃBenchmark is for national average for all critical care patients. National average of 54.5 reflects the current practice of critical care in the US for a large adult population.

MELD-Na Score

2021 – 2023

The acuity and complexity of the MILU patient population is very high, as demonstrated by the overall APACHE III score, which is well above the national average of 54 from a population that reflects the current practice of critical care in the US.¹ Similar to APACHE scoring system, the MELD-Na score reflects the severity of liver illness. In 2023, the average MELD-Na was 27.2. The average MELD-Na score for those patients receiving transplants was 35.5 in 2023. Over the past five years, we have seen expedited efforts in pre-op optimization and transplant evaluation for a sicker patient population with ACLF. 66% of the patients transplanted from MILU met the criteria for ACLF and had comparable 1-year post-transplant survival to non-ACLF patients. MILU is one of the few centers in the country that offers MARS , an albumin dialysis therapy, as a bridge to recovery or transplant for patients with ALF and ACLF.

ACLF = acute on chronic liver failure, ALF = acute liver failure, APACHE = The Acute Physiology and Chronic Health Evaluation system, MARS = Molecular Adsorbent Recirculating System, MELD-Na = model for end-stage liver disease-sodium added, MILU = Medical Intensive Liver Unit

Reference

  1. Lilly CM, Zuckerman IH, Badawi O, Riker RR. Benchmark data from more than 240,000 adults that reflect the current practice of critical care in the United States. Chest. 2011 Nov;140(5):1232-1242.
MILU ICU Mortality Rate (Observed to Expected)

2021 – 2023

MILU Hospital Mortality Rate (Observed to Expected)

2021 – 2023

MILU = Medical Intensive Liver Unit

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The above graphs reflected the Standard Mortality Ratio compared to similar institutions.

MILU Discharge From Hospital Location

2021 – 2023

MILU = Medical Intensive Liver Unit

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A key outcome is the percentage of patients discharged to home or rehabilitation (either at home or a facility), which continues to rise.