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Li C, Hu H, Bai C, Xu H, Liu L, Tang S. Alpha-fetoprotein and APRI as predictive markers for patients with Type C hepatitis B-related acute-on-chronic liver failure: a retrospective study. BMC Gastroenterol 2024; 24:191. [PMID: 38834942 PMCID: PMC11151586 DOI: 10.1186/s12876-024-03276-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2023] [Accepted: 05/23/2024] [Indexed: 06/06/2024] Open
Abstract
BACKGROUND Type C hepatitis B-related acute-on-chronic liver failure (HBV-ACLF), which is based on decompensated cirrhosis, has different laboratory tests, precipitating events, organ failure and clinical outcomes. The predictors of prognosis for type C HBV-ACLF patients are different from those for other subgroups. This study aimed to construct a novel, short-term prognostic score that applied serological indicators of hepatic regeneration and noninvasive assessment of liver fibrosis to predict outcomes in patients with type C HBV-ACLF. METHOD Patients with type C HBV-ACLF were observed for 90 days. Demographic information, clinical examination, and laboratory test results of the enrolled patients were collected. Univariate and multivariate logistic regression were performed to identify independent prognostic factors and develop a novel prognostic scoring system. A receiver operating characteristic (ROC) curve was used to analyse the performance of the model. RESULTS A total of 224 patients with type C HBV-ACLF were finally included. The overall survival rate within 90 days was 47.77%. Age, total bilirubin (TBil), international normalized ratio (INR), alpha-fetoprotein (AFP), white blood cell (WBC), serum sodium (Na), and aspartate aminotransferase/platelet ratio index (APRI) were found to be independent prognostic factors. According to the results of the logistic regression analysis, a new prognostic model (named the A3Twin score) was established. The area under the curve (AUC) of the receiver operating characteristic curve (ROC) was 0.851 [95% CI (0.801-0.901)], the sensitivity was 78.8%, and the specificity was 71.8%, which were significantly higher than those of the MELD, IMELD, MELD-Na, TACIA and COSSH-ACLF II scores (all P < 0.001). Patients with lower A3Twin scores (<-9.07) survived longer. CONCLUSIONS A new prognostic scoring system for patients with type C HBV-ACLF based on seven routine indices was established in our study and can accurately predict short-term mortality and might be used to guide clinical management.
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Affiliation(s)
- Chunyan Li
- Department of Gastroenterology, The General Hospital of Western Theater Command, Chengdu, 610083, Sichuan, China
| | - Hao Hu
- Endoscopy Center and Endoscopy Research Institute, Shanghai Collaborative Innovation Center of Endoscopy, Zhongshan Hospital, Fudan University, Shanghai, 200032, China
| | - Chengzhi Bai
- Department of Gastroenterology, The General Hospital of Western Theater Command, Chengdu, 610083, Sichuan, China
| | - Huaqian Xu
- Department of Gastroenterology, The General Hospital of Western Theater Command, Chengdu, 610083, Sichuan, China
| | - Lin Liu
- Department of Gastroenterology, The General Hospital of Western Theater Command, Chengdu, 610083, Sichuan, China
| | - Shanhong Tang
- Department of Gastroenterology, The General Hospital of Western Theater Command, Chengdu, 610083, Sichuan, China.
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Aggarwal A, Biswas S, Arora U, Vaishnav M, Shenoy A, Swaroop S, Agarwal A, Elhence A, Kumar R, Goel A, Shalimar. Definitions, Etiologies, and Outcomes of Acute on Chronic Liver Failure: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00425-7. [PMID: 38750869 DOI: 10.1016/j.cgh.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is a major public health concern. We aimed to assess the definitions, etiologic spectrum, organ failure (OF), and outcomes of ACLF globally. METHODS Three databases were searched for studies on ACLF from 1990 until September 2022. Information regarding definitions, acute precipitants, underlying chronic liver disease (CLD), OF, and mortality were extracted. Meta-analyses were performed for pooled prevalence rates (95% confidence interval [CI]) using random-effects model for each definition of ACLF. RESULTS Of the 11,451 studies identified, 114 articles (142 cohorts encompassing 210,239 patients) met the eligibility criteria. Most studies (53.2%) used the European Association for the Study of the Liver (EASL) definition, followed by Asia-Pacific Association for the Study of the Liver (APASL) (33.3%). Systemic infection was the major acute precipitant, and alcohol use was the major cause of CLD in EASL-defined studies, whereas alcohol was both the major acute precipitant and cause of CLD in APASL-defined studies. Liver failure was the major OF in APASL-based studies, whereas renal failure was predominant in EASL-based studies. Thirty-day mortality varied across definitions: APASL: 38.9%, 95% CI, 31.2%-46.9%; EASL: 47.9%, 95% CI, 42.2%-53.5%; and NACSELD: 52.2%, 95% CI, 51.9%-52.5%. Diagnostic overlap between definitions ranged from 7.7% to 80.2%. Meta-regression suggested that the World Health Organization region influenced 30-day mortality in studies using EASL definition. CONCLUSIONS Heterogeneity in the definition of ACLF proposed by different expert societies and regional preferences in its use result in differences in clinical phenotype and outcomes. A uniform definition would enhance the comparability and interpretation of global data.
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Affiliation(s)
- Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Abhishek Shenoy
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Ayush Agarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Amit Goel
- Department of Hepatology, Sanjay Gandhi Institute of Medical Sciences, Lucknow, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India.
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Hafsa F, Chaudary ZI, Tariq O, Riaz Z, Shehzad A, Irfan Jamil M, Naeem I. Acute-on-Chronic Liver Failure: Causes, Clinical Parameters, and Predictors of Mortality. Cureus 2024; 16:e52690. [PMID: 38384602 PMCID: PMC10879658 DOI: 10.7759/cureus.52690] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 01/21/2024] [Indexed: 02/23/2024] Open
Abstract
Objectives This study aimed to identify the causes, clinical characteristics, and 28-day in-hospital mortality predictors in patients with acute-on-chronic liver failure (ACLF). Methods A cross-sectional study enrolled sixty-four patients aged 18-70 years with acute-on-chronic liver failure. The study was conducted at the Gastroenterology Department, Lahore General Hospital. The study classified ACLF according to the criteria of the European Association for the Study of the Liver - Chronic Liver Failure (EASL-CLIF). Patients were followed for 28 days for mortality outcomes. The outcomes between Survivor and Non-survivor groups were compared using the Chi-Square/Fisher's Exact Test for categorical variables and the Mann-Whitney U test for continuous variables. Results In this study, age and duration of chronic liver disease were not significantly different between survivors and non-survivors. The etiology of liver disease and ACLF causes had no impact on 28-day mortality. Non-survivors had lower mean arterial pressure, and higher mortality was linked with lower Glasgow Coma Scale scores, upper gastrointestinal bleeding, and Grade IV hepatic encephalopathy. Significant differences in bilirubin, serum creatinine, urea, and C-reactive protein levels were observed at 28 days. Survival rates were highest with single organ failure (35.94%) and decreased with multiple organ failures. The overall survival rate was 51.56%. Predictive validity for mortality was assessed using the Area Under the Curve (AUC), with Child-Turcotte-Pugh (CTP) at 0.679, Model for End-Stage Liver Disease (MELD) at 0.819, and Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) at 0.771. Conclusion This study concludes that in acute-on-chronic liver failure, factors like age, gender, and disease etiology do not significantly predict 28-day mortality. Key mortality indicators include clinical parameters such as lower Glasgow Coma Scale scores, hepatic encephalopathy Grade IV, and laboratory findings like elevated bilirubin and serum creatinine. The MELD score is the most compelling prognostic tool.
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Affiliation(s)
- Fatima Hafsa
- Gastroenterology, Lahore General Hospital, Lahore, Lahore, PAK
| | | | | | - Zainab Riaz
- General Medicine, Lahore General Hospital, Lahore, PAK
| | - Aamir Shehzad
- Gastroenterology, Lahore General Hospital, Lahore, PAK
| | | | - Iqra Naeem
- Psychiatry and Behavioral Sciences, Lahore General Hospital, Lahore, PAK
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Marginean CM, Pirscoveanu D, Popescu M, Vasile CM, Docea AO, Mitruț R, Mărginean IC, Iacob GA, Firu DM, Mitruț P. Challenges in Diagnosis and Therapeutic Approach of Acute on Chronic Liver Failure-A Review of Current Evidence. Biomedicines 2023; 11:1840. [PMID: 37509478 PMCID: PMC10376368 DOI: 10.3390/biomedicines11071840] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 06/23/2023] [Accepted: 06/25/2023] [Indexed: 07/30/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute and severe decompensation of chronic liver disease (CLD) correlated with multiple organ failure, poor prognosis, and increased mortality. In 40-50% of ACLF cases, the trigger is not recognized; for many of these patients, bacterial translocation associated with systemic inflammation is thought to be the determining factor; in the other 50% of patients, sepsis, alcohol consumption, and reactivation of chronic viral hepatitis are the most frequently described trigger factors. Other conditions considered precipitating factors are less common, including acute alcoholic hepatitis, major surgery, TIPS insertion, or inadequate paracentesis without albumin substitution. Host response is likely the primary factor predicting ACLF severity and prognosis, the host immune response having a particular significance in this syndrome, together with the inflammatory cascade. The management of ACLF includes both the prevention of the precipitating factors that lead to acute liver decompensation and the support of vital functions, the prevention and management of complications, the estimation of prognosis, and the opportunity for liver transplantation.
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Affiliation(s)
- Cristina Maria Marginean
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Denisa Pirscoveanu
- Department of Neurology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Mihaela Popescu
- Department of Endocrinology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Corina Maria Vasile
- Department of Pediatric Cardiology, "Marie Curie" Emergency Children's Hospital, 041451 Bucharest, Romania
| | - Anca Oana Docea
- Department of Toxicology, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Radu Mitruț
- Department of Cardiology, University and Emergency Hospital, 050098 Bucharest, Romania
| | | | - George Alexandru Iacob
- Faculty of Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Dan Mihai Firu
- Ph.D. School Department, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
| | - Paul Mitruț
- Department of Internal Medicine, University of Medicine and Pharmacy of Craiova, 200349 Craiova, Romania
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Chapin S, Kaplan DE, Taddei T, Mahmud N. Association between statin exposure and short-term mortality in patients with high-grade acute-on-chronic liver failure. JHEP Rep 2023; 5:100740. [PMID: 37215188 PMCID: PMC10193237 DOI: 10.1016/j.jhepr.2023.100740] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2023] [Revised: 03/01/2023] [Accepted: 03/02/2023] [Indexed: 05/24/2023] Open
Abstract
Background & Aims Acute-on-chronic liver failure (ACLF) carries a high short-term mortality for patients with cirrhosis. Prior literature suggests that statin exposure may reduce the likelihood of ACLF events. However, it is unclear if statin exposure is associated with ACLF-related mortality. This study sought to determine the association between statin use and short-term mortality among patients hospitalised with ACLF. Methods This was a retrospective cohort study of Veterans Health Administration (VHA) patients diagnosed with cirrhosis between 2008 and 2021 and hospitalised with high-grade (2 or 3) ACLF. Patients were stratified into those with and without continuous statin exposure for at least 90 days prior to hospitalisation. Multivariable logistic regression models were created to determine the adjusted association between statin exposure and 28-day and 90-day mortality. Categorical statin dose exposure, converted to simvastatin equivalents, was also explored. Results A total of 11,731 patients with cirrhosis hospitalised with Grade 2 or 3 ACLF were included in the analytic cohort, 26% of whom had statin exposure. In adjusted logistic regression models, statin use was associated with 18% lower odds of ACLF-related 28-day mortality (odds ratio [OR] 0.82, 95% CI 0.73-0.93, p = 0.001) and 24% lower odds of 90-day mortality (OR 0.76, 95% CI 0.68-0.86, p <0.001). Increasing statin dose exposure was also associated with further reductions in 90-day mortality (e.g. OR 0.81, 95% CI 0.70-0.93 for 10-40 mg vs. 0 mg and OR 0.72, 95% CI 0.60-0.87 for 80 mg vs. 0 mg, p <0.001). Conclusions In this large, retrospective cohort study, statin exposure before high-grade ACLF hospitalisation was associated with reduced odds of 28-day and 90-day mortality in patients with cirrhosis. A statin dose-dependent reduction in 90-day ACLF-related mortality was also observed. Impact and Implications Statins have been identified as a class of medications with potential beneficial effects for patients with cirrhosis. In this large, retrospective cohort study of patients with cirrhosis who seek care at the Veterans Health Administration, statin use was associated with a decrease in short term (28-day and 90-day) mortality as a result of acute-on-chronic liver failure. Future prospective studies are needed to further clarify the relative safety and efficacy of statin therapy in reducing morbidity and mortality associated with acute-on-chronic liver failure in patients with cirrhosis.
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Affiliation(s)
- Sara Chapin
- Department of Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - David E. Kaplan
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
| | - Tamar Taddei
- VA Connecticut-Healthcare System, West Haven, CT, USA
| | - Nadim Mahmud
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA, USA
- Center for Clinical Epidemiology and Biostatistics, Department of Biostatistics, Epidemiology & Informatics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
- Leonard David Institute of Health Economics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Zhou J, Ye D, Zhang S, Chen Z, Xu F, Ren S, Zhang Y, Zheng H, Hu Z. Impact of donor diabetes mellitus status on liver transplant outcomes in patients with acute-on-chronic liver failure. Expert Rev Gastroenterol Hepatol 2023; 17:509-517. [PMID: 36976912 DOI: 10.1080/17474124.2023.2197210] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/30/2023]
Abstract
BACKGROUND Liver transplantation (LT) is the most effective way to save patients with acute-on-chronic liver failure (ACLF). However, the impact of donor diabetes mellitus (DM) on LT outcomes in patients with ACLF has not been fully investigated. RESEARCH DESIGN AND METHODS We retrospectively analyzed data from the Scientific Registry of Transplant Recipients (SRTR) between Janunary 1st, 2008 to December 31st, 2017 in this study. All the patients were divided into donors with DM and without DM group (DM: 1,394; non-DM: 11,138). We compared the overall survival (OS) and graft survival (GS) across different estimated ACLF (estACLF) grades between two groups. RESULTS There were 25.10% estACLF-3 patients in the entire cohort. And in estACLF-3 patients, 318 patients had DM donors. The estACLF-3 associated 5-year OS rate in the non-DM group was 74.6%, significantly better than that in the DM group, with corresponding survival rate at 64.9% (P < 0.001). Donor DM was an independent predictor for OS in the entire cohort as well as in estACLF-3 patients. CONCLUSIONS Donor DM was associated with inferior outcomes of LT in patients with estACLF-3. However, the differences were not obvious in recipients with other estACLF grades.
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Affiliation(s)
- Jie Zhou
- First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Danni Ye
- First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Siyao Zhang
- Fourth Affiliated Hospital, Zhejiang University, School of Medicine, Yiwu, China
| | - Zheng Chen
- Fourth Affiliated Hospital, Zhejiang University, School of Medicine, Yiwu, China
| | - Fangshen Xu
- Fourth Affiliated Hospital, Zhejiang University, School of Medicine, Yiwu, China
| | - Shenli Ren
- Fourth Affiliated Hospital, Zhejiang University, School of Medicine, Yiwu, China
| | - Yu Zhang
- First Affiliated Hospital, Zhejiang University, School of Medicine, Hangzhou, China
| | - Huilin Zheng
- Zhejiang University of Science and Technology, Hangzhou, China
| | - Zhenhua Hu
- Fourth Affiliated Hospital, Zhejiang University, School of Medicine, Yiwu, China
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Mezzano G, Cárdenas A, Aguilar F, Pavesi M, Solé C, Napoleone L, Graupera I, Juanola A, Carol M, Pose E, Fabrellas N, Hernaez R, Martínez J, Saliba F, Arroyo V, Sola E, Gines P. Hyperkalemia influences the outcome of patients with cirrhosis with acute decompensation (AD) and acute-on-chronic liver failure (ACLF). Dig Liver Dis 2021; 53:738-745. [PMID: 33446445 DOI: 10.1016/j.dld.2020.12.009] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2020] [Revised: 12/14/2020] [Accepted: 12/15/2020] [Indexed: 12/11/2022]
Abstract
INTRODUCTION The presence of hyperkalemia in different clinical scenarios has been described as a risk factor for mortality. Information about this electrolyte disorder in patients with cirrhosis is limited and there are no data in patients with acute-on-chronic liver failure (ACLF). AIM The aim of this study was to investigate whether hyperkalemia is a risk factor for mortality in patients with cirrhosis and acute decompensation (AD) with and without ACLF. METHODS We performed an analysis of the Chronic Liver Failure Consortium CANONIC database in 1,314 consecutive patients admitted to 29 European centers with AD both with and without associated ACLF (294 and 1020 respectively). Hyperkalemia was defined as serum potassium ≥ 5.0 mEq/L. All patients had at least one valid measure of serum potassium from admission and/or through the whole hospitalization. RESULTS 1314 patients were admitted with AD and 294 of them had ACLF at admission. Prevalence of hyperkalemia was significantly higher in ACLF versus AD (22.4% and 8.6% respectively, p<0.001). Hyperkalemia was associated with an increased 90, 180 and 360-day mortality risk in ACLF compared to AD (HR 10 vs 2.3 at 90-day p<0.001, 8.9 vs 3.1 at 180-day, p<0.001 and 5.8 vs 3.8 at 360-day, p<0.001). In a multivariate analysis, the presence of hyperkalemia during admission was independently associated with 90-day mortality [HR 2.4 (1.7 - 3.4)]. Variability of potassium between two valid measures ≥ 0.9 mg/dl was always also associated with a higher mortality rate. Addition of hyperkalemia to MELD score (MELD-K model) improved the accuracy to predict 90-day mortality risk. CONCLUSIONS Hyperkalemia is an independent risk factor of mortality in patients with AD and ACLF. Addition of hyperkalemia to the MELD score improves diagnostic accuracy to predict 90-day mortality in patients with AD and ACLF.
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Affiliation(s)
- Gabriel Mezzano
- Liver Unit, Hospital Clinic, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), y Centro de Investigaciones en Red Hepaticas y Digestivas (CIBERehd), Barcelona, Catalonia, Spain
| | - Andrés Cárdenas
- Liver Unit, Hospital Clinic, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), y Centro de Investigaciones en Red Hepaticas y Digestivas (CIBERehd), Barcelona, Catalonia, Spain; GI Unit, Hospital Clinic, Spain; Faculty of Medicine and health sciences, University of Barcelona
| | - Ferrán Aguilar
- EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Marco Pavesi
- EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Cristina Solé
- Liver Unit, Hospital Clinic, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), y Centro de Investigaciones en Red Hepaticas y Digestivas (CIBERehd), Barcelona, Catalonia, Spain
| | - Laura Napoleone
- Liver Unit, Hospital Clinic, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), y Centro de Investigaciones en Red Hepaticas y Digestivas (CIBERehd), Barcelona, Catalonia, Spain
| | - Isabel Graupera
- Liver Unit, Hospital Clinic, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), y Centro de Investigaciones en Red Hepaticas y Digestivas (CIBERehd), Barcelona, Catalonia, Spain; Faculty of Medicine and health sciences, University of Barcelona
| | - Adrià Juanola
- Liver Unit, Hospital Clinic, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), y Centro de Investigaciones en Red Hepaticas y Digestivas (CIBERehd), Barcelona, Catalonia, Spain
| | - Marta Carol
- Liver Unit, Hospital Clinic, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), y Centro de Investigaciones en Red Hepaticas y Digestivas (CIBERehd), Barcelona, Catalonia, Spain; Faculty of Medicine and health sciences, University of Barcelona
| | - Elisa Pose
- Liver Unit, Hospital Clinic, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), y Centro de Investigaciones en Red Hepaticas y Digestivas (CIBERehd), Barcelona, Catalonia, Spain
| | - Nuria Fabrellas
- Liver Unit, Hospital Clinic, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), y Centro de Investigaciones en Red Hepaticas y Digestivas (CIBERehd), Barcelona, Catalonia, Spain; Faculty of Medicine and health sciences, University of Barcelona
| | - Ruben Hernaez
- Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX Center, Houston, TX, United States
| | - Javier Martínez
- Department of Gastroenterology and Hepatology, Hospital Universitario Ramón y Cajal, Madrid, Spain
| | - Faouzi Saliba
- AP-HP Hôpital Paul Brousse Centre Hépato-Biliaire, University Paris-Sud, Villejuif, France
| | - Vicente Arroyo
- EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain
| | - Elsa Sola
- Liver Unit, Hospital Clinic, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), y Centro de Investigaciones en Red Hepaticas y Digestivas (CIBERehd), Barcelona, Catalonia, Spain
| | - Pere Gines
- Liver Unit, Hospital Clinic, Spain; Institut d'Investigacions Biomediques August Pi I Sunyer (IDIBAPS), y Centro de Investigaciones en Red Hepaticas y Digestivas (CIBERehd), Barcelona, Catalonia, Spain; Faculty of Medicine and health sciences, University of Barcelona.
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Shah S, Goldberg DS, Kaplan DE, Sundaram V, Taddei TH, Mahmud N. Patient Frailty Is Independently Associated With the Risk of Hospitalization for Acute-on-Chronic Liver Failure. Liver Transpl 2021; 27:16-26. [PMID: 32946660 PMCID: PMC8249075 DOI: 10.1002/lt.25896] [Citation(s) in RCA: 21] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2020] [Revised: 08/12/2020] [Accepted: 08/24/2020] [Indexed: 12/17/2022]
Abstract
There is significant interest in identifying risk factors associated with acute-on-chronic liver failure (ACLF). In transplant candidates, frailty predicts wait-list mortality and posttransplant outcomes. However, the impact of frailty on ACLF development and mortality is unknown. This was a retrospective study of US veterans with cirrhosis identified between 2008 and 2016. First hospitalizations were characterized as ACLF or non-ACLF admissions. Prehospitalization patient frailty was ascertained using a validated score based on administrative coding data. We used logistic regression to investigate the impact of an increasing frailty score on the odds of ACLF hospitalization and short-term ACLF mortality. Cox regression was used to analyze the association between frailty and longterm survival from hospitalization. We identified 16,561 cirrhosis hospitalizations over a median follow-up of 4.19 years (interquartile range, 2.47-6.34 years). In adjusted models, increasing frailty score was associated with significantly increased odds of ACLF hospitalization versus non-ACLF hospitalization (odds ratio, 1.03 per point; 95% CI 1.02-1.03; P < 0.001). By contrast, frailty score was not associated with ACLF 28- or 90-day mortality (P = 0.13 and P = 0.33, respectively). In an adjusted Cox analysis of all hospitalizations, increasing frailty scores were associated with poorer longterm survival from the time of hospitalization (hazard ratio, 1.02 per 5 points; 95% confidence interval, 1.01-1.03; P = 0.004). Frailty increases the likelihood of ACLF hospitalization among patients with cirrhosis, but it does not impact short-term ACLF mortality. These findings have implications for clinicians caring for frail outpatients with cirrhosis, including tailored follow-up, risk mitigation strategies, and possible expedited transplant evaluation.
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Affiliation(s)
- Shivani Shah
- Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - David S. Goldberg
- Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
| | - David E. Kaplan
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT
- VA Connecticut Healthcare System, West Haven, CT
| | - Nadim Mahmud
- Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
- Division of Gastroenterology and Hepatology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
- Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA
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Value of Liver Regeneration in Predicting Short-Term Prognosis for Patients with Hepatitis B-Related Acute-on-Chronic Liver Failure. BIOMED RESEARCH INTERNATIONAL 2020; 2020:5062873. [PMID: 32832550 PMCID: PMC7428825 DOI: 10.1155/2020/5062873] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/01/2020] [Revised: 06/21/2020] [Accepted: 07/14/2020] [Indexed: 12/30/2022]
Abstract
Background and Aims The value of hepatocyte regeneration in predicting the outcomes of hepatitis B-related acute-on-chronic liver failure (HBV-ACLF) is not fully assessed. The present study was aimed at establishing a novel scoring system to predict patients' outcomes within 3 months by applying serological indicators of hepatic regeneration and liver injury. Methods Patients with chronic hepatitis B who had a rapid deterioration were investigated. Patients were observed for 90 days, and the endpoint of follow-up was death or liver transplantation. Serum parameters were estimated on the diagnosis of acute-on-chronic liver failure (ACLF). Cox proportional hazard regression was used to identify independent prognostic factors and create a novel prognostic scoring system, and a receiver operating characteristic (ROC) curve was used to analyze the performance of the model. Results A total of 308 patients with HBV-ACLF were incorporated and divided into the training cohort (n = 206) and testing cohort (n = 102) randomly. Creatine (Cre), age, total bilirubin (TBil), alpha-fetoprotein (AFP), and international normalized ratio (INR) were found to be independent prognostic factors. According to the results of Cox regression analysis, a new prognostic model (we named it the TACIA score) was calculated. The areas under ROC (AUROC) for the new model were 0.861 and 0.763 in the training and testing cohorts, respectively, and patients with lower TACIA scores (<4.34) would survive longer (P < 0.001). Conclusions A pertinent prognostic scoring system for patients with HBV-ACLF was established in our study, and the novel model could predict patients' short-term survival effectively.
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Pérez-Hernández O, González-Reimers E, Quintero-Platt G, Abreu-González P, Vega-Prieto MJDL, Sánchez-Pérez MJ, Martín-González C, Martínez-Riera A, Santolaria-Fernández F. Malondialdehyde as a Prognostic Factor in Alcoholic Hepatitis. Alcohol Alcohol 2018; 52:305-310. [PMID: 28007738 DOI: 10.1093/alcalc/agw094] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2016] [Accepted: 11/14/2016] [Indexed: 12/20/2022] Open
Abstract
Aims Alcoholic hepatitis is a severe complication of alcoholism, associated with high short-term mortality. Although pathogenesis remains obscure, it is generally accepted that lipopolysaccharide-induced cytokine secretion with further generation of reactive oxygen species (ROS) play outstanding roles. Prognosis is uncertain, and the usually employed prognostic scores do not include variables related to ROS generation. Therefore, this study was performed to assess short-term prognostic value of cytokines, nutritional status, different scores [Maddrey, model for end-stage liver disease (MELD), albumin, bilirubin, INR, creatinine index (ABIC), Lille, Glasgow, MELD-Na, Child-Pugh] and malondialdehyde (MDA, as an indicator of lipid peroxidation) at admission and after 1 week, among patients affected by severe acute alcoholic hepatitis (Maddrey index >32). Methods Sixty-two patients affected by severe acute alcoholic hepatitis, for whom we calculated Maddrey, MELD, ABIC, Lille, Glasgow, MELD-Na, Child-Pugh, and determined serum MDA and interleukin (IL)-6, IL-8, IL-4, tumor necrosis factor alpha and interferon gamma levels at admission and after 1 week. Results Twenty-four patients died during the follow-up period. MDA showed a better prognostic accuracy than the aforementioned scores, both at admission and after 1 week. Conclusion Our study supports the importance of including MDA assessment in the prognostic evaluation of patients with alcoholic hepatitis. Short summary Alcoholic hepatitis is associated with high short-term mortality. Although not included in prognostic scores, lipid peroxidation plays an outstanding role in its pathogenesis. We found that malondialdehyde levels showed a better prognostic accuracy than the usually employed scores. Therefore, it should be included in the prognostic evaluation of these patients.
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Affiliation(s)
- Onán Pérez-Hernández
- Servicio de Medicina Interna, Hospital Universitario de Canarias,Universidad de La Laguna, Tenerife, Canary Islands, Spain
| | - Emilio González-Reimers
- Servicio de Medicina Interna, Hospital Universitario de Canarias,Universidad de La Laguna, Tenerife, Canary Islands, Spain
| | - Geraldine Quintero-Platt
- Servicio de Medicina Interna, Hospital Universitario de Canarias,Universidad de La Laguna, Tenerife, Canary Islands, Spain
| | - Pedro Abreu-González
- Departamento de Fisiología, Hospital Universitario de Canarias, Universidad de La Laguna, Tenerife, Canary Islands,Spain
| | - María José de la Vega-Prieto
- Servicio de Laboratorio, Hospital Universitario de Canarias,Universidad de La Laguna, Tenerife, Canary Islands, Spain
| | - María José Sánchez-Pérez
- Servicio de Medicina Interna, Hospital Universitario de Canarias,Universidad de La Laguna, Tenerife, Canary Islands, Spain
| | - Candelaria Martín-González
- Servicio de Medicina Interna, Hospital Universitario de Canarias,Universidad de La Laguna, Tenerife, Canary Islands, Spain
| | - Antonio Martínez-Riera
- Servicio de Medicina Interna, Hospital Universitario de Canarias,Universidad de La Laguna, Tenerife, Canary Islands, Spain
| | - Francisco Santolaria-Fernández
- Servicio de Medicina Interna, Hospital Universitario de Canarias,Universidad de La Laguna, Tenerife, Canary Islands, Spain
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Kulkarni S, Sharma M, Rao PN, Gupta R, Reddy DN. Acute on Chronic Liver Failure-In-Hospital Predictors of Mortality in ICU. J Clin Exp Hepatol 2018; 8:144-155. [PMID: 29892177 PMCID: PMC5992306 DOI: 10.1016/j.jceh.2017.11.008] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/28/2017] [Accepted: 11/17/2017] [Indexed: 12/12/2022] Open
Abstract
AIMS We studied in-hospital predictors of mortality of acute on chronic liver failure (ACLF) in Indian patients. METHODS Patients admitted to the intensive care unit of our institute fulfilling the definition of ACLF based on the Asia-Pacific Association for Study of Liver Disease (APASL) consensus were included. Complete history and medical evaluation to assess the etiology of underlying liver cirrhosis and to identify the acute precipitating insult of worsening liver function was done. Data was prospectively recorded and various scoring systems and individual clinical and laboratory parameters were assessed to identify predictors of 28 days mortality. RESULTS 64 out of 240 patients screened for ACLF were analyszed in the study. Median age was 44 years and 53% were males. Alcohol was the primary cause of cirrhosis in 60.93%. Infections and active alcoholism was the main precipitating acute insult in 43% and 37% patients respectively. 28% patients had history of ingestion of hepato-toxic drugs as the acute insult. More than one acute insult was seen in 37.5% patients and type-II hepatic injury was the most common type. 28 days in hospital mortality was 43.75% and was highest in patients with sepsis (67.8%). Presence of hepato-renal syndrome and need for ventilation was associated with poor outcome. Though multiple variables were significant in predicting mortality on univariate analysis, yet on regression model only APACHE II and shock could significantly predict mortality with odds ratio of 3.18 and 9.14 respectively. Highest mortality was seen with cerebral and lung as organ failure and mortality increased as the number of organ failure worsened. CLIF-SOFA and APACHE-II scores having area under curve > 0.8 had higher ability to predict mortality. CONCLUSION ACLF carries high short-term mortality and early intervention by liver transplantation should be considered in patients who shows high risk of mortality.
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Affiliation(s)
| | - Mithun Sharma
- Address for correspondence: Mithun Sharma, Department of Gastroenterology and Hepatology, Asian Institute of Gastroenterology, Hyderabad, India.
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Blasco-Algora S, Masegosa-Ataz J, Gutiérrez-García ML, Alonso-López S, Fernández-Rodríguez CM. Acute-on-chronic liver failure: Pathogenesis, prognostic factors and management. World J Gastroenterol 2015; 21:12125-40. [PMID: 26576097 PMCID: PMC4641130 DOI: 10.3748/wjg.v21.i42.12125] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 08/17/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is increasingly recognized as a complex syndrome that is reversible in many cases. It is characterized by an acute deterioration of liver function in the background of a pre-existing chronic liver disease often associated with a high short-term mortality rate. Organ failure (OF) is always associated, and plays a key role in determining the course, and the outcome of the disease. The definition of ACLF remains controversial due to its overall ambiguity, with several disparate criteria among various associations dedicated to the study of liver diseases. Although the precise pathogenesis needs to be clarified, it appears that an altered host response to injury might be a contributing factor caused by immune dysfunction, ultimately leading to a pro-inflammatory status, and eventually to OF. The PIRO concept (Predisposition, Insult, Response and Organ Failure) has been proposed to better approach the underlying mechanisms. It is accepted that ACLF is a different and specific form of liver failure, where a precipitating event is always involved, even though it cannot always be ascertained. According to several studies, infections and active alcoholism often trigger ACLF. Viral hepatitis, gastrointestinal haemorrhage, or drug induced liver injury, which can also provoke the syndrome. This review mainly focuses on the physiopathology and prognostic aspects. We believe these features are essential to further understanding and providing the rationale for improveddisease management strategies.
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