Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update

Association between early antibiotic treatment after admission and mortality of acute-on-chronic liver failure patients with bacterial infection: A multicenter retrospective study

Bacterial infection is a significant risk factor in the onset and development of acute-on-chronic liver failure (ACLF). Although early broad-spectrum antibiotic treatment is recommended, the optimal time to initiate antibiotic therapy remains unclear. This study aimed to investigate the relationship between the timing of antibiotic treatment and the prognosis of ACLF patients with bacterial infection. Patients with ACLF and bacterial infections upon admission were retrospectively evaluated. The predictors of 28-day mortality were identified using univariate, least absolute shrinkage and selection operator regression analysis, and multivariate logistic regression analyses. The "survminer" R package was used to categorize patients into two groups based on a 6-h threshold: early antibiotic administration (<6 h of admission) and later antibiotic administration (≥6 h after admission). A total of 295 patients were evaluated. The lungs were the most common site of infection (61.7% of patients had lung infections), followed by the peritoneum (25.4% of patients had spontaneous bacterial peritonitis). The time to first antibiotic administration was an independent predictor of 28-day mortality, and the odds of mortality increased by 2% for each hourly delay in antibiotic administration after admission. In Kaplan-Meier survival analysis, both 28-day and 90-day mortality rates were significantly lower in the early antibiotic group than in the later antibiotic group (both p < 0.0001). In conclusion, early antibiotic treatment is an independent predictor of 28-day mortality in ACLF patients with bacterial infections. Patients who received antibiotics less than 6 hours after admission exhibited lower 28- and 90-day mortality rates.

Aetiology of chronic liver disease is a valuable factor for stratifying adverse outcomes of acute decompensation: prospective observational study

BACKGROUND/AIMS

Acute decompensation (AD) is defined as the development of complications related to portal hypertension and liver dysfunction that affect the progression of chronic liver disease (CLD) or liver cirrhosis (LC). Variations exist in patient demographics and prognostic outcomes of AD based on the aetiology of CLD, encompassing LC. However, limited research has been conducted to analyse these discrepancies across aetiologies.

METHODS

The prospective Korean Acute-on-Chronic Liver Failure (KACLiF) cohort consisted of 1,501 patients who were hospitalized with AD of CLD from July 2015 to August 2018. In this study, we assess the clinical attributes and prognostic implications of AD with CLD/LC stratified by the aetiology.

RESULTS

Among 1,501 patients, the mean age was 54.7 years old and 1,118 patients (74.5%) were men. The common events of AD were GI bleeding (35.3%) and jaundice (35.0%). There was a median follow-up of 8.0 months (1.0-16.0 months). The most common aetiology of CLD was alcohol (n = 1021), followed by viral hepatitis (n = 206), viral hepatitis with alcohol-related (n = 129), cryptogenic (n = 108) and autoimmune (n = 37). Viral hepatitis with alcohol-related CLD showed a poor liver function profile and a high frequency of acute-on-chronic liver failure (ACLF) [22.1% vs. 19.6% (alcohol CLD), 8.1% (viral CLD), 5.6% (autoimmune related CLD and 16.0% (cryptogenic CLD)] with worse adverse outcomes (mortality or liver transplantation) than other aetiologies. The difference in aetiology was a significant factor for 28-day adverse outcomes in multivariate analysis even in a high MELD score (≥15), which indicated poor baseline liver function and prognosis (p < 0.001).

CONCLUSION

The aetiology of CLD constitutes a pivotal determinant influencing both short- and long-term adverse outcomes of AD in CLD, even among individuals presenting with elevated MELD scores. Notably, patients afflicted with viral hepatitis should exercise caution even in the consumption of modest quantities of alcohol that induced the exacerbations in the adverse outcomes associated with AD.

Novel prognostic scoring models for hepatitis B virus-related acute-on-chronic liver failure: A comparison with classical models

Early diagnosis and accurate prognostic evaluation are important for guiding clinical treatment and reducing mortality in patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF). The present study established novel prognostic scoring models to guide the clinical treatment of patients with HBV-ACLF. We performed a retrospective analysis of clinical data from two cohorts of patients diagnosed with HBV-ACLF. By comparing differences in baseline characteristics and clinical indicators between the survival (n = 102) and dead (n = 64) groups in the derivation cohort(n = 166), four laboratory indicators (age, INR, TBIL, and HBeAg status) and three clinical signs (extrahepatic infection, ascites, and hepatic encephalopathy) were identified as independent risk factors. Logistic regression and nomogram models were used to construct three novel predictive models. By comparing the death and survival groups, we found that the three new models had higher predictions for AUROC (average of 0.856) than the three old models (average of 0.773). Model 1 had the strongest predictive power for the short-term survival rate of HBV-ACLF patients. Finally, we verified the predictive value of the new models for HBV-ACLF in a validation cohort (n = 42), and the Model 2 demonstrated good predictive accuracy for the 30-day survival rate of patients. The novel model based on seven predictors could accurately predict short-term mortality in patients with HBV-ACLF, which is promising for guiding clinical management and addressing the aetiological differences in Asian populations.

Living Donor Liver Transplantation for Pediatric Wilson's Disease-related Acute Liver Failure-Hard Work With High Rewards

Background

Liver transplantation (LT) is indicated for children with Wilson's disease (WD) presenting with acute liver failure (ALF) or with chronic liver disease (CLD) that has progressed to decompensation. We present our experience of living donor liver transplantation (LDLT) for pediatric WD, discuss the challenges of managing WD-ALF and compare outcomes of children presenting with WD-ALF with WD-CLD.

Methods

We compared presentation and outcomes of the WD-ALF and WD-CLD cohorts. Fifty-three children (WD-ALF: 28 (53%), WD-CLD: 25 (47%)) underwent LDLT for WD.

Results

WD-ALF group had higher Kings New Wilson Index (KNWI) (15 vs 9, P = 0.001), higher pediatric end-stage liver disease/model for end-stage liver disease score (35 vs 20, P = 0.001), were more frequently encephalopathic (64% vs 4%, P = 0.001), and had ongoing hemolysis (86% vs 28%, <0.001). Preoperative mechanical ventilation, operative continuous renal replacement therapy (CRRT), therapeutic plasma exchange (TPE) was needed in 32%, 46.5%, and 89% of WD-ALF children, respectively. WD-ALF patients had longer postoperative ICU stay (4.5 days vs 3 days, P = 0.001), longer hospital stay (20.5 days vs 14 days, P = 0.001), more major complications (57% vs 20%, P = 0.006). WD-ALF cohort also had more postoperative neurological complications (42.9% vs 8%, P = 0.004) and invasive fungal infections (21.4% vs none, P = 0.024). There were two perioperative (90 day) mortalities in WD-ALF group and none in WD-CLD group. Patient survival of the entire cohort at median follow-up of 26 months was 94.3% and all survivors had good allograft function neurological sequelae. Patient survival was inferior for WD-ALF cohort though the difference was not statistically significant (88.5% vs 100%, log rank test, P = 0.089).

Conclusion

LDLT is a curative treatment for children with WD with excellent short-term and long-term outcomes. WD-ALF patients can have a complicated postoperative course but have good long-term survival.

Predictors of Mortality in Patients Diagnosed With Autoimmune Hepatitis - Insights from a Prospective, 90-day Follow--up Study

Background and aims

The response to corticosteroids and optimal timing for liver transplantation (LT) in patients with autoimmune hepatitis (AIH) remain significant clinical challenges. This study aimed to assess short-term (90-day) mortality in patients with acute AIH (with or without underlying cirrhosis and chronic liver disease) treated with corticosteroids, and to identify factors that predict mortality in this population.

Methods

We conducted a prospective, single-center study between 2022 and 2024, involving patients with histologically confirmed AIH. All patients received corticosteroid treatment and were monitored for various clinical and laboratory parameters on days 3, 7, and 90 after initiating therapy.

Results

A total of 104 patients were included in the study, with a mean age of 46.1 ± 14.3 years; 77% of the patients were female. The 90-day mortality rate following the initiation of corticosteroids was 13.47%. Univariate analysis identified several significant predictors of mortality, including older age, diabetes mellitus, cirrhosis, esophageal varices, hepatic encephalopathy, low serum albumin on day 3, model of end-stage liver disease (MELD) scores on days 3 and 7, and the survival and prognostic factors for acute severe autoimmune hepatitis (SURFASA) score (P < 0.05). Multivariate analysis revealed that MELD score on day 7 (odds ratio [OR] 1.25; 95% confidence interval [CI] {1.09-1.48}; P = 0.00) and SURFASA score (OR 7.46; 95% CI {1.05-53.06}; P = 0.04) were significant. Specifically, a MELD score ≥27.5 on day 7 (area under the receiver operating characteristic curve [AUC] = 0.998) with 100% sensitivity and 97.8% specificity, and a SURFASA score ≥ -2.95 (AUC = 0.969) with 100% sensitivity and 95.6% specificity were highly predictive of mortality.

Conclusion

Despite corticosteroid treatment, mortality rates remain high in the decompensated AIH and acute on chronic liver failure-AIH groups. The SURFASA score, along with MELD scores on days 3 and 7, are strong predictors of mortality and can assist clinicians in making timely decisions regarding referral for early liver transplantation.

Non-Cell-Based Extracorporeal Artificial Liver Systems: Historic Perspectives, Approaches and Mechanisms, Current Applications, and Challenges

BACKGROUND

Liver disease is a growing burden. Transplant organs are scarce. Extracorporeal liver support systems (ELSS) are a bridge to transplantation for eligible patients. For transplant-ineligible patients the objective becomes liver recovery.

METHODS

We review seven decades of non-cell-based ELSS research in humans. Where possible, we emphasize randomized controlled trials (RCTs). When RCTs are not available, we describe the available human clinical data.

RESULTS

There are three broad cell-free approaches to remove protein-bound toxins (PBTs) and treat liver failure. The first is a dialysate binder suspension. A material that binds the PBT (the binder) is added to the dialysate. Binders include albumin, charcoal, and polystyrene sulfonate sodium. The unbound fraction of the PBT crosses the dialyzer membrane along a chemical gradient and binds to the binder. The second approach is using grains of sorbent fixed in a plastic housing to remove PBTs. Toxin-laden blood or plasma flows directly through the column. Toxins are removed by binding to the sorbent. The third approach is exchanging toxin-laden blood, or fractions of blood, for a healthy donor blood product. Most systems lack widespread acceptance, but plasma exchange (PE) is recommended in many guidelines. The large donor plasma requirement of PE creates demand for systems to complement or replace it.

CONCLUSIONS

Now that PE has become recommended in some, but not all, jurisdictions, we discuss the importance of reporting precise PE protocols and dose. Our work provides an overview of promising new systems and lessons from old technologies to enable ELSS improvement.

Bacterial Infections in Patients With Severe Alcohol-Associated Hepatitis: Drivers of Organ Failure and Mortality

BACKGROUND

Severe alcohol-associated hepatitis (sAH) is a life-threatening condition with limited treatment options. Although corticosteroids offer some benefit in short-term survival, their use remains controversial due to concerns about increased infection risk. Infections are a major cause of mortality in sAH; however, the reasons for this remain unclear.

METHODS

A post hoc analysis of the prospective VTL-308 multicentre trial on 151 patients with sAH was performed. Competing-risk models evaluated predictors of infections, the influence of corticosteroids on infection risk, and the impact of infections on the clinical outcomes up to 1 year of follow-up.

RESULTS

Among 151 patients, 90 (59.6%) developed infections. The most frequent were urinary tract (34.4%) and bloodstream (30%) infections. The causative pathogen was isolated in 40 patients, with Enterococcus spp. being the most common (35%). Fungal infections were detected in 19 (12.6%) patients. Corticosteroid use was not associated with increased bacterial (subdistribution-hazard ratio [sHR] =0.74; 95% Confidence Interval (CI): 0.42-1.33; p = 0.32) or fungal infection risk (sHR = 1.74; 95% CI: 0.59-5.15; p = 0.31). Infections significantly increased multi-organ failure (MOF) in the univariate (sHR = 2.31; 95% CI: 1.03-5.17; p = 0.04) and multivariate models (sHR = 2.46; 95% CI: 1.12-5.39; p = 0.03). 37.8% of infected patients died versus 13.1% of non-infected patients. Bacterial infections strongly predicted mortality, with sHRs ranging from 5.22 to 7.78, indicating a five- to eight-fold increased risk of death (p < 0.001).

CONCLUSIONS

Infections in sAH are central drivers of MOF and mortality. Our findings highlight infections as an independent risk factor unaffected by corticosteroid use, addressing previous concerns about the safety of this treatment.

Infection risk and management in patients with cirrhosis: A critical overview

In this paper, we analyze the article published by El Labban et al, which explores the impact of cirrhosis on patients with necrotizing fasciitis. The authors conclude that cirrhosis is a significant risk factor for increased in-hospital morbidity and mortality in this patient population. Building upon their final observation regarding the importance of understanding this association, we will delve into the topic of infections in patients with liver cirrhosis. These patients exhibit intrinsic characteristics that make them particularly susceptible to infections, both bacterial and fungal. This heightened risk not only increases the likelihood of severe infections but also makes them a common trigger for acute decompensations, including the development of acute-on-chronic liver failure, which markedly worsens prognosis and mortality. Infections in patients with cirrhosis often require a more aggressive and rapid diagnostic and therapeutic approach due to the higher risk of nosocomial infections, multidrug-resistant organisms, and atypical clinical presentations. Delayed or inadequate management can lead to unfavorable outcomes, further complicating the course of their underlying liver disease. The aim of this article is to emphasize the importance of early and appropriate management in patients with cirrhosis with infections. Evidence supports that timely and tailored interventions not only improve clinical outcomes but also reduce mortality. By raising awareness among clinicians about the complexity of these cases, we hope to contribute to optimizing the care of this high-risk population.

Comparison of relaxed verses standard cut-offs of rotational thromboelastometry for guiding blood product use before invasive procedures in advanced cirrhosis: a randomized controlled trial

BACKGROUND

The cut-offs of viscoelastic hemostatic assays used for guiding blood products transfusion in patients with cirrhosis undergoing invasive procedures are arbitrary. The aim of this study was to evaluate the efficacy and safety of two different ROTEM thresholds ["relaxed" ROTEM thresholds vs. "conventional" thresholds used in liver transplantation] for prophylactic blood product transfusion for invasive procedures in advanced cirrhosis patients with impaired traditional coagulation.

MATERIAL AND METHODS

Patients with advanced cirrhosis scheduled to undergo invasive procedures with high inherent procedure bleeding risk or low inherent procedure bleeding risk along with the presence of any adverse patient specific factors, and abnormalities on conventional coagulation tests requiring correction (any of the following: platelet count < 30 × 109/L, INR > 2.0, and plasma fibrinogen < 100 mg/dL), were randomized to receive correction based on standard ROTEM criteria (n = 519, MELD = 26.5 ± 7.4, CTP score = 12.4 ± 2.3, intrinsic low-risk procedure with any high-risk patient factors = 72.2%, intrinsic high-risk procedure with/without high-risk patient factors = 27.8%) or relaxed ROTEM criteria (n = 524, MELD = 25.6 ± 8.0, CTP score = 12.2 ± 2.7, intrinsic low-risk procedure with any high-risk patient factors = 64.1%, intrinsic high-risk procedure with/without high-risk patient factors = 35.9%). Patients in the standard and relaxed criteria groups received blood components using the following triggers, respectively: Fresh frozen plasma (FFP, 10 ml/kg) when EXTEM-CT > 80 or > 90 s; one pooled of single donor platelet unit or 6 pooled units of random donor platelet when EXTEM-MCF/ FIBTEM-MCF < 35/ ≥ 8 mm or < 30/ ≥ 7 mm; and 5 pooled units of cryoprecipitate if EXTEM-MCF/ FIBTEM-MCF < 35 / < 8 mm or < 30/ < 7 mm. The primary outcome measure was the proportion of patients requiring any blood products transfusion (i.e., FFP /platelets /cryoprecipitate).

RESULTS

The proportion of patients transfused any blood product (FFP, platelets or cryoprecipitate) was 287/524 (54.8%) in the relaxed ROTEM group versus 352/519 (67.8%) in the standard ROTEM group (p < 0.001). Procedure-related bleeding and non-bleeding complications and 28-day mortality were similar in both the groups.

CONCLUSIONS

Relaxation of ROTEM cut-offs leads to lower prophylactic blood products transfusions without increased risk of bleeding in patients with advanced cirrhosis undergoing invasive procedures.

EASL-CLIF, NACSELD and APASL definitions for identification of acute-on-chronic liver failure and its outcome in a non-transplant setting

BACKGROUND AND OBJECTIVES

Chronic liver diseases (CLD) may progress to cirrhosis, decompensation and death. An intervening insult may lead to acute decompensation (AD); patients with AD may fulfil criteria for acute-on-chronic liver failure (AD-ACLF). While the outcome of ACLF and priority for liver transplantation have been studied, data on outcome in a non-transplant setting is sparse. We evaluated three international consensus criteria for definition of ACLF to determine the number of patients satisfying these definitions and their accuracy in predicting mortality and compare mortality in a non-transplant setting.

METHODS

Total 341 consecutive patients with CLD of any etiology were enrolled and followed up. All significant clinical events and changes in laboratory data were noted to classify patients into no AD, AD-ACLF and AD-non-ACLF.

RESULTS

Total 150 (44%) patients had non-alcoholic fatty liver disease as etiology. As many as 197 (57.8%) patients had AD; of these, 54 (27.4%) met at least one definition of ACLF: 50 (92.6%) fulfilled EASL-CLIF criteria, 31 (57.4%) NACSELD and 22 (40.7%) APASL. The most common precipitating event (59.2%) was infection. Forty-six (13.5%) patients died during the study period - 52% of those with AD-ACLF and 12.6% with AD-non-ACLF (p < 0.00001). The accuracy of EASL-CLIF, NACSELD and APASL definitions in determining mortality was 79.7%, 86.3% and 77.7%, respectively.

CONCLUSION

Total 16% of patients with CLD developed AD-ACLF by any definition; one-half of them died. EASL-CLIF criteria identified maximum number of patients with AD-ACLF, but NACSELD criteria had highest accuracy for predicting mortality in AD-ACLF. These findings may help prioritize patients with ACLF for intensive care in the absence of easy access to liver transplantation.

Predictive factors and clinical outcomes in decompensated non-cirrhotic chronic hepatitis B patients treated with entecavir or tenofovir disoproxil fumarate

BACKGROUND & AIMS

Little is known about the short-term and long-term outcomes of non-cirrhotic chronic hepatitis B (CHB) patients who experience hepatic decompensation. Therefore, this study aimed to investigate the clinical outcomes of decompensated non-cirrhotic CHB patients.

METHODS

We conducted a retrospective study and enrolled a total of 304 decompensated non-cirrhotic CHB patients. Cox regression model was used to analyze factors associated with all-cause mortality. Additionally, the incidence of HBsAg seroclearance and its associated factors were estimated by the competing risk analysis.

RESULTS

The median follow-up time was 4.36 years (IQR 1.04-7.16). Out of the total enrolled patients, 63 (20.72 %) patients either died or underwent liver transplantation, and 14 patients achieved HBsAg seroclearance. Risk factors associated with 1-month, 3-month, and long-term all-cause mortality were the presence of ascites and hepatic encephalopathy, baseline HBV DNA levels, and MELD scores. The cumulative incidence of HBsAg seroclearance was 1.78 %, 3.72 %, 4.25 %, 5.68 %, 5.68 %, 8.28 %, and 8.28 % at the 1-year, 2-year, 3-year, 4-year, 5-year, 6-year, and 7-year follow-up, respectively. Independent predictors for HBsAg seroclearance were baseline alanine aminotransferase (ALT)≧ 25 times upper limit of normal (subdistribution hazard ratio [sHR] = 5.97; 95 %CI, 1.82-19.63; p = 0.0032) and HBV DNA <5 log10 IU/ml (sHR = 4.43; 95 %CI, 1.55-12.63; p = 0.0054).

CONCLUSIONS

The presence of ascites and hepatic encephalopathy, baseline HBV DNA levels, and MELD scores were associated with short-term and long-term all-cause mortality. Additionally, lower HBV DNA levels and higher ALT levels at baseline were independently predictive of sequential HBsAg seroclearance.

Hepatitis A and E Viruses Are Important Agents of Acute Severe Hepatitis in Asia: A Narrative Review

Acute-on-chronic liver failure (ACLF) and acute liver failure (ALF) are severe hepatitis that occur in patients with and without chronic liver diseases and/or cirrhosis, respectively, and both often result in death. Hepatitis A virus (HAV) and hepatitis E virus (HEV) infection can cause these severe conditions. We reviewed the role of HAV and HEV, which infect humans through the fecal-oral route, in ALF and ACLF in Asian countries. This narrative review was the derived from a traditional non-systematic review. Hepatitis A should be recognized as one of the sexually transmitted infections, especially among men who have sex with men. HAV genotype IIIA infection seems to present a more severe clinical manifestation. Acute HEV-1 infection is associated with ALF in pregnant women in India. HEV-4, rather than HEV-3, was found in severe hepatitis in Japan. HEV also plays a role as a cause of acute insult and/or chronic liver disease in immunocompromised patients with ACLF. Further studies are needed for the development of vaccines and antivirals against HAV and HEV infections. Despite the limitations of the recording of cases and the extent of specific vaccinations, multidisciplinary cooperation, involving hepatologists, virologists, experts in public health, etc., may improve the treatment of HAV and HEV infection.

Clinical trajectories in liver cirrhosis: An evidence-based reappraisal for the internist

Over the last few years, the approach to clinical recognition and risk stratification of advanced liver disease has changed substantially, and liver cirrhosis has been increasingly conceptualized as a clinical rather than a histopathologic condition. In this Clinical Insight, we summarize the latest developments on recognition and management of 'clinically' advanced chronic liver disease.

Serum Interleukin-6 Levels may be a Key Determinant of 6-week Further Decompensation Risk in Patients With Cirrhosis and Acute Variceal Bleed: A Proof of Concept Study

Background and aims

Limited data exist on the role of systemic inflammation and gut barrier dysfunction in acute variceal bleed (AVB). We studied inflammatory markers and changes in the intestinal barrier in patients with AVB and assessed if these can be used to identify a higher risk subgroup with regard to outcomes.

Methods

In this prospective observational study, patients with cirrhosis and AVB presenting at a tertiary care center were stratified by whether or not they developed acute decompensation (AD) over 6 weeks follow-up. Utility of systemic inflammatory markers (interleukin-6 [IL-6], C-reactive protein), endotoxinemia (serum IgM/IgG anti-endotoxin antibodies), and duodenal epithelial tight junction proteins (TJPs) by immunohistochemistry (IHC) for tight-junction proteins (claudin-2,-4, zonula occludens-1(ZO-1), junctional adhesion molecule (JAM)) was assessed to predict the outcomes. These parameters were compared with a pre-existing cohort of patients with cirrhosis and no recent variceal bleed and with those without cirrhosis (dyspepsia with no endoscopic pathology). A nomogram was developed from multivariate model to predict 6-wk AD in patients with AVB.

Results

Patients with AVB(n = 66) (age:46.4 ± 11.7 years; etiology: alcohol/NASH/HBV/HCV [48.5%/12.1%/12.1%/7.6%]) were included. Twenty-four (36.3%) patients developed 6-wk AD. Patients with 6-wk AD had higher serum IL-6 (median: 156.14 pg/ml [IQR: 136.12-170.52] vs 58.28 pg/ml [31.70-110.67]; P < 0.001) and Child score (median: 9 [6.75-10.25] vs 7 [6-9]; P = 0.042) at baseline. Serum endotoxinemia and duodenal epithelial TJP were similar. A nomogram combining CTP and IL-6 was generated that predicted 6-wk AD with optimism-corrected c-statistic of 0.87. Comparison with non-bleeder cirrhosis (n = 52) (7.57 [5.48-9.87]) and dyspepsia controls (n = 53) (5.72 [4.40-6.45]; P < 0.001) also identified significant elevation of serum IL-6, not entirely explainable by derangements in TJP and bacterial translocation markers.

Conclusion

6-wk AD rates in patients with cirrhosis and AVB can be predicted using combination of Child score and serum IL-6.

Sterile systemic inflammation reaction associated with 90-day mortality in patients with HBV-related acute-on-chronic liver failure

BACKGROUND

Acute-on-chronic liver failure (ACLF) represents the terminal and most lethal phase of acute decompensated cirrhosis. Systemic inflammation plays a critical role in the pathogenesis of ACLF. Systemic inflammation reaction syndrome (SIRS) is a marker of ongoing inflammation. Therefore, we aim to evaluate the relationship of sterile SIRS with hepatitis B virus (HBV)-related ACLF (HBV-ACLF).

METHODS

HBV-ACLF patients with sterile SIRS who were hospitalized between December 2016 and December 2018 were retrospectively analyzed. All patients were followed up until 90 days. Risk factors associated with 90-day mortality and sterile SIRS development were assessed.

RESULTS

Among 151 HBV-ACLF patients without infection, 37 patients (24.5%) presented with or developed sterile SIRS. During the 90-day follow-up, 23 of the 37 patients with sterile SIRS died (62.2%), compared to 40 patients without sterile SIRS (35.1%, P  = 0.004). Univariate analysis showed that age, total bilirubin (TBIL), international normalized ratio, ammonia, presence of sterile SIRS, model for end-stage liver disease score, presence of complications, and organ failures were associated with 90-day mortality. In multivariate analyses, the presence of sterile SIRS was an independent risk factor for 90-day mortality. Among SIRS components, heart rate (HR) was the most frequently met criterion (56 patients, 37.09%). Patients who met the HR or temperature criterion had lower 90-day survival rate than those who did not (46.4 vs 65.3%, P  = 0.020; 16.7 vs 60.0%, P  = 0.020).

CONCLUSION

The presence of sterile SIRS in HBV-ACLF patients was closely associated with prognosis.

Extracorporeal liver support systems in patients with acute-on-chronic liver failure: An updated systematic review and meta-analysis

BACKGROUND

The utilization of extracorporeal liver support systems is increasingly prevalent for the management of acute-on-chronic liver failure in clinical settings. Yet, the efficacy of these interventions in terms of tangible clinical benefits for patients remains a matter of debate, underscoring the need for meta-analysis.

METHODS

An updated meta-analysis was performed to elucidate the relationship between the application of extracorporeal liver support versus standard pharmacological treatment and the prognostic endpoints of patient survival, specifically assessing 1-month and 3-month mortality rates, as well as the incidence of complications such as hepatic encephalopathy, spontaneous bacterial peritonitis, and hepatorenal syndrome. Literature were searched via PubMed, EMBASE, and Web of Science.

RESULTS

The meta-analysis revealed the following: the odds ratio for 1-month mortality was 0.63 (95% confidence interval [CIs]: 0.51-0.76), for 3-month mortality was 0.70 (95% CI: 0.61-0.81), for hepatic encephalopathy was 0.81 (95% CI: 0.67-0.97), for spontaneous bacterial peritonitis was 0.66 (95% CI: 0.44-0.99), and for hepatorenal syndrome was 0.68 (95% CI: 0.51-0.92). These results suggest that patients with acute-on-chronic liver failure undergoing extracorporeal liver support system therapy have significantly better survival rates and lower complication incidences compared to those receiving conventional drug therapy. Further subgroup analysis indicated that patients with lower model for end-stage liver disease (MELD) scores and reduced total bilirubin (Tbil) levels demonstrated greater benefits from extracorporeal hepatic support.

CONCLUSION

This study establishes that in the management of acute-on-chronic liver failure, extracorporeal liver support systems confer a survival advantage and reduce complications relative to standard pharmacotherapy.

Therapeutic Plasma Exchange in Patients With Acute-On-Chronic Liver Failure Improves Survival-An Updated Meta-Analysis

BACKGROUND AND AIM

Acute-on-chronic liver failure (ACLF) is a syndrome that develops after an acute insult and is associated with organ failures and high short-term mortality. Plasma exchange (PLEX) is an emerging modality for treating ACLF patients. We aimed to evaluate the efficacy of PLEX in treating ACLF.

METHODS

We conducted a systematic review and meta-analysis of studies comparing PLEX versus standard medical therapy (SMT) to treat patients with ACLF across different definitions and etiologies. Pooled risk ratios were determined by the Mantel-Haenszel method within a random effect model. The primary outcome studied was survival at 30 days in PLEX group compared to SMT.

RESULTS

Twenty-three studies (5336 ACLF patients with 2724 in PLEX arm, including 4 RCTs) were included. PLEX was associated with a significant reduction in mortality at 30 days (RR 0.70; 95% CI, 0.60-0.81; p < 0.001) and at 90 days (RR 0.81;0.77-0.86; p < 0.001). Six studies (1495 patients; 2 RCTs) with data for 1-year survival showed better outcomes in the PLEX group (RR 0.85; 0.79-0.92; p < 0.0001) compared to SMT. Among HBV-related ACLF and alcohol-related ACLF, there was a significant reduction in mortality among PLEX treated group at 90 days; RR 0.79 (0.74-0.85), p < 0.001 and RR 0.69 (0.52-0.92), p = 0.01 respectively. PLEX was associated with improved 3-month survival across definitions for ACLF. The most common adverse effects were skin rash and allergic reactions (14%).

CONCLUSIONS

In this up-to-date meta-analysis, significant 1, 3-month and up to 1-year survival benefit was noted among patients with ACLF treated with PLEX compared to SMT.

The restoration of immunity characterized by the recovery of myeloid dendritic cells represent a favorable response to methylprednisolone therapy for HBV-ACLF patients: A prospective cohort study

BACKGROUND

The use of methylprednisolone (MP) is still controversial for hepatitis B virus related acute-on-chronic liver failure (HBV-ACLF). We aimed to explore the change in dendritic cells (DCs) during MP treatment in HBV-ACLF to guide the use of MP to improve patient's prognosis.

METHODS

Patients with HBV-ACLF were prospectively allocated to groups given methylprednisolone intravenously (1.5 mg/kg/day for the first 3 days, 1 mg/kg/day for the second 2 days, and 0.5 mg/kg/day for the last 2 days, MP group, n = 36) plus standard treatment or standard treatment only (CM group, n = 34). The phenotype [myeloid and plasmacytoid DCs (mDCs, pDCs)] and function of DCs (IL-12 and IFN-α production) were measured at baseline (0d), 3d, 7d, 10d, 14d, 28d, and then monthly until 3 months. Patients' survival was assessed until day 90.

RESULTS

The 3-month survival rate was significantly higher in the MP group than the control (72.0 % vs. 35.5 %，P < 0.01). The phenotype and function of DCs were suppressed in the MP group. The mDCs counts was lower in non-survivors compared to survivors at baseline. Patients with a decline in mDCs counts at the 7th day and a continuous increase in mDCs counts from the 10th day presented a better outcome for patients with MP treatment. Bilirubin was the only relative factor for the restoration of mDCs in the MP group (odds ratio, 0.991; 95 % confidence interval, 0.984-0.999; P = 0.023).

CONCLUSIONS

Methylprednisolone could improve the outcome of HBV-ACLF by inhibiting the circulating mDCs counts. And the recovery of mDCs counts after methylprednisolone treatment could represent a favorable response. We can consider monitoring the circulating DCs counts to guide the use of MP in HBV-ACLF in order to improve patient outcomes.

Comparative Analysis of Plasmapheresis Versus Plasmapheresis Combined With Continuous Renal Replacement Therapy in Adult Liver Failure: A Retrospective Observational Study

BACKGROUND

Liver failure constitutes a critical medical condition marked by the rapid decline in hepatic functions. Novel therapeutic approaches, including therapeutic plasma exchange (TPE) and continuous venovenous hemodiafiltration (CVVHDF), have emerged as promising modalities for mitigating the effects of this condition by facilitating detoxification and enhancing liver function. The efficacy of these interventions, whether administered individually or in combination, is a prominent area of investigation in the management of liver failure among adult populations. This study aims to evaluate the role and effectiveness of TPE, both as a standalone treatment and in conjunction with CVVHDF, in the management of liver failure in adult patients.

METHODS

This retrospective study was conducted in a Liver Transplant Intensive Care Unit (LTICU), focusing on the medical records of adult patients aged 35 to 62 years. The patient cohort consisted of individuals admitted between January 1, 2021, and June 1, 2024, due to acute liver failure or acute-on-chronic liver failure. The analysis specifically included patients who underwent therapeutic plasma exchange (TPE) or those who received continuous renal replacement therapy in conjunction with TPE. For the statistical analysis, a P-value of less than .05 was deemed indicative of statistical significance. The study encompassed a total of 47 patients with liver failure, comprising 23 males and 24 females. Among these patients, 25 (53.2%) received only TPE, while 22 (46.8%) were treated with a combination of TPE and continuous venovenous hemodiafiltration (CVVHDF).

RESULTS

In the cohort of patients who received only therapeutic plasma exchange (TPE), the median International Normalized Ratio (INR) improved significantly, decreasing from 2 (1.6-2.6) to 1.3 (1.1-1.7). Similarly, alanine aminotransferase levels reduced from 351 (66-1482) to 166 (71-367), while aspartate aminotransferase levels decreased from 259 (132-1392) to 86 (35-160). In the group receiving a combination of TPE and continuous venovenous hemodiafiltration (CVVHDF), notable reductions were also observed: INR decreased from 3 (2.4-4.7) to 1.5 (1.3-2.4), alanine aminotransferase levels dropped from 691 (59-2397) to 162 (70-1060), and aspartate aminotransferase levels fell from 916 (134-1828) to 69 (45-503). These changes were statistically significant, with P-values of less than .05 for each parameter in both treatment groups. Overall, 21 patients achieved survival without requiring a liver transplant, while 7 patients underwent liver transplantation, resulting in a transplant-free survival rate of 44.7%.

CONCLUSION

The findings from our study on the management of liver failure in adults demonstrate that both therapeutic plasma exchange (TPE) administered alone and in conjunction with continuous venovenous hemodiafiltration (CVVHDF) are effective treatment modalities, particularly as a bridging strategy to liver transplantation. The observed transplant-free survival rate of 44.7% underscores the significant clinical advantages of these therapies. However, to enhance the validity of these results and their applicability in broader clinical contexts, additional multicenter studies are essential for further exploration of these treatment approaches in liver failure management.

Predicting futile outcomes following deceased donor liver transplantation in non-HCC patients with MELD-Na score above 30: a retrospective international multicenter cohort study

INTRODUCTION

In the current "sickest first" allocation policy for limited deceased liver grafts, identifying patients "too sick to transplant" before transplantation is crucial to optimize outcomes. This study aimed to predict futile outcomes following deceased donor liver transplantation (DDLT) in patients with model for end-stage liver disease-sodium (MELD-Na) scores ≥30.

METHODS

This international multicenter study was conducted as part of the International Society of Liver Surgeons. We collected data from patients with a MELD-Na score of ≥30 who underwent DDLT. A total of 994 patients were enrolled between 2010 and 2021, including 654 from the Republic of Korea, 224 from the USA, and 116 from other regions. Futility was defined as death within 3 months or during the hospital stay following a DDLT. After exclusion, 160 (16.6%) patients were classified into a futile group and 803 (83.4%) into a non-futile group.

RESULTS

The MELD-Na scores collected at three time points (listing, matching, and transplantation) were comparable between the groups ( P = 0.442, P = 0.180, and P = 0.554, respectively). Regarding concomitant organ failure factors, the futile group showed a higher incidence of organ dysfunction across all measured parameters, including the use of mechanical ventilators, continuous renal replacement therapy (CRRT), pneumonia, bacteremia, and vasopressor use (all P < 0.01). Independent risk factors for futile outcome were recipient age (≥65 years), body mass index (<18.5 kg/m 2 ), mechanical ventilator use, CRRT (≥1 week), and prolonged intensive care unit stay before transplantation (≥2 weeks). The futility rate was 53.3% in patients with ≥3 risk factors ( P < 0.001). We developed a nomogram to predict futility after DDLT based on multivariate regression analysis, which showed a better predictive power than previous models.

CONCLUSION

The risk factors and new nomogram, which adequately reflect concomitant organ failure before liver transplantation, could effectively predict the risk of futile outcomes after DDLT and contribute to decision-making regarding transplantation eligibility in clinical practice.

Liver transplant-facilitated CD161+Vα7.2+ MAIT cell recovery demonstrates clinical benefits in hepatic failure patients

Mucosal-associated invariant T (MAIT) cells exert multifaceted effects such as anti-microbial activity, tissue repair, and pro-fibrotic effects across various disease settings. Nonetheless, their role in liver injury and hemostasis remains debated. Here, we report a significant depletion and functional dysregulation of MAIT cells, which is associated with disease severity and accumulated bile acids in HBV-infected patients with varying degree of liver injury. Liver transplantation facilitates a gradual recovery of recipient-originated MAIT cells. Transcriptome analysis reveals enhanced MAIT cell activation, while TCR mining demonstrates clonotype overlap between circulating and hepatic MAIT cells during significant liver injury. TCR-activated MAIT cells from transplant recipients display higher protective capacity but reduced pathological potential than those from liver failure patients. Compromised recovery of MAIT cells is linked to post-transplantation complications, whereas prompt recovery predicates favorable clinical outcome. These findings underscore the intricate interplay between MAIT cells and the hepatic environment, highlighting MAIT cells as potential therapeutic targets and sensitive predictors for clinical outcome in individuals experiencing liver failure and post liver transplantation.

Predictive factors and prognostic models for Hepatic arterial infusion chemotherapy in Hepatocellular carcinoma: a comprehensive review

Hepatocellular carcinoma (HCC) is a prevalent and lethal cancer, often diagnosed at advanced stages where traditional treatments such as surgical resection, liver transplantation, and locoregional therapies provide limited benefits. Hepatic arterial infusion chemotherapy (HAIC) has emerged as a promising treatment modality for advanced HCC, enhancing anti-tumor efficacy through targeted drug delivery while minimizing systemic side effects. However, the heterogeneous nature of HCC leads to variable responses to HAIC, highlighting the necessity for reliable predictive indicators to tailor personalized treatment strategies. This review explores the factors influencing HAIC success, including patient demographics, tumor characteristics, biomarkers, genomic profiles, and advanced imaging techniques such as radiomics and deep learning models. Additionally, the synergistic potential of HAIC combined with immunotherapy and molecular targeted therapies is examined, demonstrating improved survival outcomes. Prognostic scoring systems and nomograms that integrate clinical, molecular, and imaging data are discussed as superior tools for individualized prognostication compared to traditional staging systems. Understanding these predictors is essential for optimizing HAIC efficacy and enhancing survival and quality of life for patients with advanced HCC. Future research directions include large-scale prospective studies, integration of multi-omics data, and advancements in artificial intelligence to refine predictive models and further personalize treatment approaches.

Risk factors and prognosis of pulmonary infection in hepatitis B-related acute-on-chronic liver failure: a retrospective cohort study

OBJECTIVE

To identify risk factors for pulmonary infection in patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF), assess its impact on prognosis, and develop a prognostic prediction model.

METHODS

We retrospectively analyzed the clinical data of 393 patients with HBV-ACLF. Logistic regression was used to analyze the risk factors for lung infection in ACLF patients, as well as the factors affecting the prognosis of those who were infected. Additionally, a prognostic prediction model was established using the Nomogram method.

RESULTS

The incidence of pulmonary infections in patients with ACLF was 38.7%, and patients with ACLF combined with pulmonary infections had a higher short-term mortality rate than those without infections (65.71% vs. 35.02%). Multivariate logistic regression analysis indicated that independent risk factors for pulmonary infection included TBIL, CRP, invasive procedures, peritoneal effusion, and hepatic encephalopathy. Additionally, creatinine, INR, comorbid diabetes mellitus, neutrophil counts, and lymphocyte counts were identified as independent risk factors affecting 30-day mortality in patients with pulmonary infection. Incorporating these risk factors, a new predictive model was established, with an area under the receiver operating characteristic curve of 0.832 (95% CI, 0.765-0.900). This model demonstrated higher discriminatory performance compared to traditional prognostic models such as CTP, MELD, and MELD-Na, with statistically significant differences (P < 0.05).

CONCLUSION

HBV-ACLF patients are susceptible to pulmonary infection, with fungal infection posing a significant threat. Pulmonary infection is associated with worse prognosis in HBV-ACLF patients. Early identification of risk factors and prognostic assessment can facilitate timely intervention and improve prognosis.

Efficacy of recombinant human thrombopoietin in patients with acute-on-chronic liver failure and thrombocytopenia: A prospective, open-label study

BACKGROUND

Patients with acute-on-chronic liver failure (ACLF) have a high mortality rate, poor prognosis, and often experience concurrent thrombocytopenia and bleeding events.

AIM

To evaluate the efficacy and safety of recombinant human thrombopoietin (rhTPO) in patients with ACLF with concomitant severe thrombocytopenia.

METHODS

This was a prospective, open-label study. We assigned 70 ACLF patients with severe thrombocytopenia into the rhTPO group and control group, with 35 patients in each group. Patients in the rhTPO group received subcutaneous injections of rhTPO at a dose of 15000 IU/day for 7 consecutive days, while patients in the control group did not receive rhTPO treatment. The primary endpoint was the proportion of patients with platelet count > 50 × 109/L on day 14.

RESULTS

The proportion of patients with platelet count > 50 × 109/L on day 14 was 60.7% in the rhTPO group, which was significantly higher than that (12.0%) in the control group (P < 0.001). The platelet count in the rhTPO group on day 14 was 64 × 109/L, exceeding the baseline of 28 × 109/L. Compared to the control group, the rhTPO group exhibited a significant increase in platelet count from baseline (P < 0.05). Model for end-stage liver disease score, albumin level and international normalized ratio improved significantly from baseline on day 14 after rhTPO injection. The concentrations of serum thrombopoietin and hepatocyte growth factor in the rhTPO group after 7 days were 143.7 and 195.4 pg/mL, respectively, showing a significant increase from baseline (P < 0.05). Eight (22.9%) patients had bleeding events in the control group compared with four (11.4%) in the rhTPO group. The incidence of 90-day mortality was also higher in the control group (6, 17.1%) than that in the rhTPO group (3, 8.6%).

CONCLUSION

rhTPO significantly increased the platelet count in ACLF patients with thrombocytopenia and reduce the occurrence of bleeding events, with a good safety profile.

Liver failure diagnosis: key diagnostic biomarkers discovery and bioinformatic validation

Background

Glutathione peroxidase 3 (GPX3) is a strong antioxidant. While elevated GPX3 levels are linked to diverse pathologies, its role in liver failure (LF) remains underexplored. This study investigates GPX3's diagnostic potential and mechanistic contributions to LF pathogenesis.

Methods

We integrated two high-quality liver tissue datasets (GSE38941 and GSE14668) from the Gene Expression Omnibus (GEO) database. Gene Ontology and Kyoto Encyclopedia of Genes and Genomes analyses were conducted to identify potential biomarkers associated with liver failure. The Comparative Toxicogenomics Database was used to predict the function of GPX3. In addition, in our study, we verified the target gene mRNA expression level in 40 patients with acute or chronic acute liver failure (ACHBLF) by RT-QCPR experiment and detect the methylation status of GPX3 promoter of ACHBLF patients with methylation specific PCR (MSP).

Results

The results demonstrate that GPX3 drives pathogenic mechanisms in liver failure through oxidative stress-related pathways (e.g., collagen cross-linking, extracellular matrix remodeling) and immune dysregulation (e.g., macrophage activation, PD-1/CTLA-4 signaling). CPX8, PRDX6, GPX4, GSS, GSR, TXN, GPX7, PPARGC1A, ALOX15, and ALOX5 have been identified as key immune-related genes. Furthermore, there were significant differences in immune cell infiltration between the high and low expression groups of GPX3 groups. Immune infiltration analysis demonstrated strong correlations between GPX3 expression and key immune markers (p < 0.05), suggesting its role in modulating inflammatory responses. Additionally, GPX3 increased susceptibility to aerosols, cyclosporin and dexamethasone was observed in patients with elevated levels of GPX3. The mRNA expression of GPX3 was much higher in ACHBLF patients than in other groups. In ACHBLF patients, the group with GPX3 methylated promoter had higher mortality than those without.

Conclusion

In conclusion, GPX3 is a promising diagnostic biomarker for liver failure. Its promoter methylation status may serve as a prognostic indicator, highlighting its therapeutic potential.

miR-126-3p Serves as a Biomarker for Hepatitis B Virus-Associated Chronic Acute Liver Failure and Regulates Inflammation by Regulating ERRFI1

Hepatitis B virus-associated chronic acute liver failure (HBV-ACLF) is the leading cause of ACLF, affecting approximately 90% of patients with ACLF. The objective of this study was to investigate the clinical relevance of miR-126-3p on HBV-ACLF as well as the regulatory impact of ERRFI1 and miR-126-3p on the inflammatory response caused by ACLF via in vitro experimental methodologies. RT-qPCR was utilized to quantify the expression levels of miR-126-3p, ERRFI1, NLRP3, caspase 1, and IL-1β. The clinical function of miR-126-3p was assessed using ROC analysis or Kaplan-Meier curve. Cell proliferation was quantified via the CCK-8 assay, while the dual-luciferase reporter assay was employed to confirm the specific binding interaction between miR-126-3p and ERRFI1. In patients with HBV-ACLF, a significant downregulation of miR-126-3p expression was observed; The level of miR-126-3p served as a prognostic indicator for the progression of HBV-ACLF, with reduced expression being associated with an unfavorable clinical outcome. In addition, miR-126-3p was found to modulate LPS-induced cell proliferation, and inflammation in THLE-2 cells through the regulation of ERRFI1 expression. Therefore, miR-126-3p might serve as a biomarker for HBV-ACLF.

Prognosis of Acute HEV Infection in Patients With Liver Cirrhosis: A Retrospective Study of 628 Chinese Patients

Acute hepatitis E virus infection is a serious global health problem, which a significant cause of morbidity and mortality. The aim of the present study was to characterise the clinical features and therapeutic response of patients with acute HEV infection and identify risk factors for poor prognosis. In a retrospective study from 01 January 2014 to 01 Januray 2022, we collected baseline data from all patients eligible for acute hepatitis E virus (HEV) infection and followed up with all patients via interviews and medical records. We explored the clinical feature of Chinese patients with acute HEV infection. The follow-up data of patients were used to identify risk factors for poor prognosis. In total, 628 acute hepatitis E (AHE) patients fulfilled the inclusion criteria and did not meet the exclusion criteria. Among them, 452 were males and 176 were females (M:F = 2.57:1). The median age at diagnosis was 57.0 years (interquartile range: 46-64 years). The median baseline serum levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST), and total bilirubin (TBIL) were elevated in this cohort (642.3 U/L, 216.2 U/L, 104.1 μmol/L, respectively). The median hospitalisation duration was 16 days. Compared with patients without other liver diseases, patients with liver cirrhosis show lower baseline ALT and AST level, poorer coagulation indices and higher MELD scores. According to multivariate analysis, liver cirrhosis, high MELD score, low albumin concentration was found to be independent predictors of poor prognosis in patients with AHE. Our study used a lager sample size to validate that some demographic and serological features were quite different between patients with/without CLDs. Liver cirrhosis was a significant independent predictor of poor prognosis in acute HEV hepatitis.

Impact of Diabetes, Drug-Induced Liver Injury, and Sepsis on Outcomes in Metabolic Dysfunction Associated Fatty Liver Disease-Related Acute-on-Chronic Liver Failure

INTRODUCTION

The prevalence of metabolic dysfunction-associated fatty liver disease (MAFLD) and its complication, MAFLD-related acute-on-chronic liver failure (MAFLD-ACLF), is rising. Yet, factors determining patient outcomes in MAFLD-ACLF remain understudied.

METHODS

Patients with MAFLD-ACLF were recruited from the Asian Pacific Association for the Study of the Liver-ACLF Research Consortium (AARC registry). The diagnosis of MAFLD-ACLF was made when the treating unit had identified the etiology of chronic liver disease as MAFLD (or previous nomenclature such as non-alcoholic fatty liver disease, non-alcoholic steatohepatitis, or non-alcoholic steatohepatitis-cirrhosis). Patients with coexisting other etiologies of chronic liver disease (such as alcohol, hepatitis B virus, hepatitis C virus, etc.) were excluded. Data were randomly split into derivation (n = 258) and validation (n = 111) cohorts at a 70:30 ratio. The primary outcome was 90-day mortality. Only the baseline clinical, laboratory features and severity scores were considered.

RESULTS

The derivation group had 258 patients; 60% were male, with a mean age of 53. Diabetes was noted in 27% and hypertension in 29%. The dominant precipitants included viral hepatitis (hepatitis A virus and hepatitis E virus, 32%), drug-induced injury (drug-induced liver injury, 29%), and sepsis (23%). Model for End-Stage Liver Disease-Sodium (MELD-Na) and AARC scores on admission averaged 32 ± 6 and 10.4 ± 1.9. At 90 days, 51% survived. Nonviral precipitant, diabetes, bilirubin, international normalized ratio, and encephalopathy were independent factors influencing mortality. Adding diabetes and precipitant to MELD-Na and AARC scores, the novel MAFLD-MELD-Na score (+12 for diabetes, +12 for nonviral precipitant), and MAFLD-AARC score (+5 for each) were formed. These outperformed the standard scores in both cohorts.

DISCUSSION

Almost half of patients with MAFLD-ACLF die within 90 days. Diabetes and nonviral precipitants such as drug-induced liver injury and sepsis lead to adverse outcomes. The new MAFLD-MELD-Na and MAFLD-AARC scores provide reliable 90-day mortality predictions for patients with MAFLD-ACLF.

Characterization of NK Cells Using Single-Cell RNA Sequencing in Patients With Acute-On-Chronic Liver Failure

BACKGROUND AND AIM

Acute-on-chronic liver failure (ACLF) is characterized by fast progression and high mortality, with systemic inflammation and immune paralysis as its key events. While natural killer (NK) cells are key innate immune cells, their unique function and subpopulation heterogeneity in ACLF have not been fully elucidated. This study aimed to investigate the characteristics of NK cell subsets in the peripheral blood of patients with ACLF and determine their roles in the inflammatory responses.

METHODS

Circulating NK cells (14 751 cells) from patients with ACLF and healthy controls (HCs) were subjected to single-cell RNA sequencing (scRNA-seq). Clustering and annotation were used to identify the features of NK cell subsets and the characteristics of disease progression in ACLF.

RESULTS

Four NK cell subsets were obtained, including adaptive NK cells, mature NK cells, inflamed NK cells, and CD56bright NK cells. Compared with the HCs, the patients with ACLF had a significantly lower proportion of Mature NK cells and a higher proportion of Inflamed NK cells. Quasi-temporal analysis showed that Inflamed NK cells were highly enriched in the late quasi-temporal sequence, and genes related to pro-inflammatory were significantly up-regulated in Inflamed NK cells. In addition, scRNA-seq and flow cytometry confirmed that the expression level of cell migration inducing hyaluronidase 2 (CEMIP2) in NK cells progressively increased from the HC group to the ACLF survival group and then to the ACLF death group.

CONCLUSIONS

scRNA-seq reveals that Inflamed NK cell subsets are associated with ACLF progression and poor prognosis. CEMIP2 may be a molecular marker for ACLF progression.

Integrating prior decompensation into ACLF definition to enhance clinical management

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a complicated syndrome associated with high short-term mortality and reversibility. Whether the prior decompensation should be included in the definition of ACLF is controversial.

METHODS

A total of 532 patients with decompensation (prior or first) of chronic liver disease were retrospectively enrolled and analyzed from January 2018 to June 2023. Clinical data were used to identify the characteristics and determine prognosis.

RESULTS

Of the 532 patients, 99 patients did not meet APASL-ACLF criteria due to the existence of prior decompensation and 433 patients met the Asian Pacific Association for the Study of the Liver (APASL)-ACLF criteria. The two groups had similar characteristics including prognosis scores (Chinese Group on the Study of Severe Hepatitis B (COSSH)-ACLF II score: 7.59 vs. 7.67, p = 0.934; Chronic Liver Failure (CLIF) Consortium ACLF score: 42.90 vs. 44.81, p = 0.273), the distribution of patients with APASL ACLF research consortium score (AARC score) (5-7: 19.2%/12.0%; 8-10: 56.6%/55.0%; 11-15: 24.2%/33.0%, p > 0.05) and the 28-/90-day mortality rates (30.5%/43.2% vs. 36.3%/43.1%, p = 0.267/0.978). In all integrated ACLF patients, Receiver Operating Characteristic (ROC) curve analysis and decision curve analysis (DCA) showed that COSSH-ACLF IIs had higher prognostic efficiency and clinical net benefit than AARC score and CLIF-C ACLFs for 28-/90-day mortality.

CONCLUSION

Prior decompensated patients exhibited clinical characteristics and high short-term mortality similar to those of first decompensated patients. The COSSH-ACLF IIs demonstrated the highest prognostic efficiency for all integrated ACLF patients. Including prior decompensation in the ACLF definition can help to simplify and improve clinical management.

Timing and Indications for Liver Transplantation for Children with Chronic Liver Disease

Chronic liver disease (CLD) in children poses significant challenges, necessitating timely management to mitigate morbidity and mortality. Liver transplantation (LT) has emerged as a transformative intervention, offering improved long-term survival for paediatric patients with CLD. This review explores the evolving landscape of liver transplantation, focusing on indications and timing considerations. The aetiology of CLD is diverse, encompassing intrahepatic, extrahepatic cholestatic conditions, metabolic diseases, malignancy, and drug-induced liver injury. LT is indicated when children exhibit signs of hepatic decompensation, necessitating a comprehensive evaluation to assess transplant suitability. Indications for LT include biliary atresia, inborn errors of metabolism, hepatocellular carcinoma, and emerging indications such as mitochondrial hepatopathies and acute on chronic liver failure. The timing of transplantation is critical, emphasizing the need for early recognition of decompensation signs to optimise outcomes. Advancements in LT techniques and immunosuppressive therapies have enhanced patient and graft survival rates. Various transplant modalities, including reduced-size LT and living-related LT, offer tailored solutions to address the unique needs of paediatric patients. While LT represents a cornerstone in the management of paediatric CLD, careful patient selection, multidisciplinary collaboration, and ongoing refinements in transplant protocols are imperative for optimizing outcomes and addressing the evolving landscape of paediatric liver disease management.

Liver transplantation improves prognosis across all grades of acute-on-chronic liver failure patients: A systematic review and meta-analysis

BACKGROUND

Liver transplantation (LT) is recognized as an effective approach that offers survival benefits for patients with acute-on-chronic liver failure (ACLF). However, controversies remain regarding the LT selection criteria, and meta-analyses reporting overall survival outcomes across different ACLF severity grades are lacking.

AIM

To depict a comprehensive postoperative picture of patients with ACLF of varying severity and contribute to updating LT selection.

METHODS

Systematic searches in Web of Science, EMBASE, PubMed, and Cochrane databases were performed, from inception to December 26, 2023, for studies exploring post-transplant outcomes among ACLF patients, stratified by severity grades as identified by the European Association for the Study of the Liver-Chronic Liver Failure criteria. The primary outcome of interest was the survival rate within one year, with post-transplant complications as secondary outcomes. Additionally, the subgroup analysis examined region-specific one-year survival rates.

RESULTS

A total of 17 studies involving 28025 participants were included. Patients with ACLF-1 and ACLF-2 have favorable survival within one year, with survival rates reaching 87% [95% confidence interval (CI): 84%-91%] and 86% (95%CI: 81%-91%), respectively. Despite the relatively lower survival (73%, 95%CI: 66%-80%) and higher incidence of infection (48%, 95%CI: 29%-67%) observed in ACLF-3 patients, their survival exceeds that of those who do not undergo LT. Moreover, post-transplant survival was highest in North America across all ACLF grades.

CONCLUSION

LT can provide survival advantages for ACLF patients. To optimize the utilization of scarce donor organs and improve prognosis, comprehensive preoperative health evaluations are essential, especially for ACLF-3 patients.

Acute-on-Chronic Liver Failure: Steps Towards Consensus

Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by organ failure and high short-term mortality. Since its first definition in 2013, many international organizations have defined this syndrome and, till now, there has been no agreement regarding definitions and diagnostic criteria. Although the precise mechanism of ACLF is unknown, precipitant factors and the systemic inflammation response play a major role. Specific management of this high-mortality syndrome is still under development, but a general consensus in the diagnosis and management of ACLF is needed.

Early prediction of invasive fungal infection risk in acute-on-chronic liver failure: a prediction model based on admission indicators

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a severe clinical syndrome, and the incidence of invasive fungal infection (IFI) among hospitalized patients with ACLF is steadily increasing. The aim of this study is to develop a diagnostic nomogram to assist in the identification of IFI in these patients.

METHODS

A retrospective study included 705 patients from January 1, 2019, to October 31, 2023, randomly divided into training (n = 493) and validation (n = 212) cohorts. The diagnosis of IFI includes proven diagnosis and probable diagnosis. Kaplan analysis was performed to analyze the survival prognosis of ACLF patients with and without IFI. A nomogram was developed based on a logistic regression model derived through least absolute shrinkage and selection operator (LASSO) regression. The discrimination, accuracy, and clinical utility of the model were assessed using receiver operating characteristic curves, Hosmer-Lemeshow tests, calibration plots, and decision curve analysis.

RESULTS

Kaplan-Meier survival analysis confirmed that the median survival time of ACLF patients with IFI was significantly lower (by 68 days) than that of ACLF patients without IFI, and there were significant differences in the 90-day, 180-day, and 360-day survival rates between the two groups (P < 0.05). Based on LASSO regression, the following factors were identified as significant risk factors for predicting IFI: aminotransferase levels, prothrombin activity, hemoglobin, neutrophil-to-lymphocyte ratio, and serum total bilirubin. A nomogram was constructed incorporating these variables. The nomogram demonstrated good discriminative ability, with an area under the receiver operating characteristic curve (AUC) of 0.78 (95% confidence interval [CI]: 0.72-0.84) in the training cohort and 0.79 (95% CI: 0.70-0.87) in the validation cohort. Decision curve analysis further validated the clinical applicability of the nomogram.

CONCLUSION

ACLF patients with IFI have lower survival time than those without IFI. A nomogram was developed and validated to assist clinicians in the early prediction of IFI in hospitalized patients with ACLF.

CLINICAL TRIAL NUMBER

Not applicable.

Safety and efficacy of PD-1 inhibitors plus tyrosine kinase inhibitors combination therapy in patients with advanced hepatocellular carcinoma combined with hyperbilirubinemia: a retrospective cohort study

Background

Programmed death-1 (PD-1) inhibitors plus tyrosine kinase inhibitors (TKIs) combination therapy are considered as a first-line treatment recommendation for advanced hepatocellular carcinoma (HCC). However, patients with hyperbilirubinemia are excluded from this therapeutic option due to limitations in indications. There is a notable absence of published studies evaluating the safety and efficacy of the PD-1 inhibitors plus TKIs combination therapy in patients with HCC combined with hyperbilirubinemia.

Methods

Patients with HCC complicated with hyperbilirubinemia who received combination therapy with PD-1 inhibitors and TKIs were retrospectively analyzed. Adverse events, tumor response, and laboratory parameters were recorded to assess the safety and efficacy of the treatment, as well as to identify potential risk factors influencing survival.

Results

A total of 108 participants were included in the study, with 56 patients (51.9%) reporting at least one adverse event, the majority of which were mild. The objective response rate (ORR) for the enrolled participants was 11.9%, and the disease control rate(DCR) reached 61.2%. The median overall survival (OS) for the entire cohort was 5.03 months, while the median progression-free survival (PFS) was 3.63 months. Multifactorial analysis showed that MELD score >18 and increased total bilirubin (TBIL) levels within one week were significant risk factors for OS. Patients with a decrease in TBIL levels within one week had significantly prolonged median OS (not reached vs 3.3months, P =0.013) and median PFS (7.03 months vs 2.77 months, P =0.010).

Conclusion

Combination therapy demonstrated favorable safety and tolerability among patients with HCC combined with hyperbilirubinemia. Patients who experienced a rapid decline in TBIL levels during the early phase of treatment with PD-1 inhibitors and TKIs were observed to derive clinical benefits. Early initiation of aggressive interventions aimed at reducing TBIL levels is recommended to optimize treatment outcomes.

A short-term predictive model for disease progression in acute-on-chronic liver failure: integrating spectral CT extracellular liver volume and clinical characteristics

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a life-threatening hepatic syndrome. Therefore, this study aimed to develop a comprehensive model combining extracellular liver volume derived from spectral CT (ECVIC-liver) and sarcopenia, for the early prediction of short-term (90-day) disease progression in ACLF.

MATERIALS AND METHODS

A retrospective cohort of 126 ACLF patients who underwent hepatic spectral CT scans was included. According to the Asia-Pacific Association for the Study of the Liver (APASL) criteria, patients were divided into the progression group (n = 70) and the stable group (n = 56). ECVIC-liver was measured on the equilibrium period (EP) images of spectral CT, and L3-SMI was measured on unenhanced CT images, with sarcopenia assessed. A comprehensive model was developed by combining independent predictors. Model performance was evaluated using receiver operating characteristic (ROC) curve analysis, calibration curves, and decision curve analysis (DCA).

RESULTS

In the univariate analysis, BMI, WBC, PLT, PTA, L3-SMI, IC-EP, Z-EP, K140-EP, NIC-EP, ECVIC-liver, and Sarcopenia demonstrated associations with disease progression status at 90 days in ACLF patients. In multivariate logistic regression, white blood cell count (WBC) (OR = 1.19, 95% CI: 1.02-1.40; P = 0.026), ECVIC-liver (OR = 1.27, 95% CI: 1.15-1.40; P < 0.001), sarcopenia (OR = 4.15, 95% CI: 1.43-12.01; P = 0.009), MELD-Na score (OR = 1.06, 95%CI: 1.01-1.13;P = 0.042), and CLIF-SOFA score (OR = 1.37, 95%CI:1.15-1.64; P<0.001) emerged as independent risk factors for ACLF progression. The combined model exhibited superior predictive performance (AUCs = 0.910, sensitivity = 80.4%, specificity = 90.0%, PPV = 0.865, NPV = 0.851) compared to CLIF-SOFA, MELD-Na, MELD and CTP scores(both P < 0.001). Calibration curves and DCA confirmed the high clinical utility of the combined model.

CONCLUSIONS

Patients without sarcopenia and/or with a lower ECVIC-liver have a better prognosis, and the integration of WBC, ECVIC-liver, Sarcopenia, CLIF-SOFA and MELD-Na scores in a composite model offers a concise and effective tool for predicting disease progression in ACLF patients.

TRIAL REGISTRATION

Not Applicable.

Clinical outcomes and predictors in patients with acute on chronic liver failure in Southern Taiwan

BACKGROUND/AIMS

The study is to analyze the clinical characteristics and identify prognostic factors as well as evaluate predictive models in patients with acute-on-chronic liver failure (ACLF) from Southern Taiwan.

METHODS

The cohort study was conducted using the Chang Gung Research Database. We included patients with ACLF based on the definition provided by the Asian-Pacific Association for the Study of the Liver ACLF Research Consortium (AARC).

RESULTS

A total of 231 patients diagnosed with ACLF were included in this study, out of which 26 patients underwent liver transplantation (LT). The primary cause of ACLF was acute exacerbation of hepatitis B virus (HBV) in 68.4% of cases and followed by severe alcoholic hepatitis (20.8%). Among LT-free patients, the 28-day mortality rate was observed to be 31%. Older age, higher INR and ammonia levels, and the presence of severe hepatic encephalopathy on 3-6 days of treatment were independent predictors of 28-day mortality. The CLIF-C ACLF and COSSH-ACLF scores, evaluated on 3-6 days, demonstrated the highest predictive performance for 28-day mortality. The optimal cut-off values for the CLIF-C ACLF and COSSH-ACLF scores were determined to be 47 and 6.3, respectively. Patients with CLIF-C ACLF score >63 or COSSH-ACLF score >8.1 experienced 100% mortality by day 28.

CONCLUSION

The CLIF-C ACLF and COSSH-ACLF scores, evaluated within one week after treatment, exhibit strong predictive capabilities for short-term mortality in ACLF patients. These models are valuable tools for guiding timely decision-making, including the consideration of liver transplantation or withdrawal from treatment.

Organ dysfunction and failure in liver disease

Acute-on-chronic liver failure (ACLF) is a complex syndrome defined by the existence of different organ failures (OFs) in patients with chronic liver disease, mainly cirrhosis. Several definitions have been proposed to define the syndrome, varying in the grade of the subjacent liver disease, the type of precipitants and the organs considered in the definition. Liver, coagulation, brain, kidney, circulatory and pulmonary are the six types of OFs proposed in the different classifications, with different prevalence worldwide. Irrespective of the definition used, patients who develop ACLF present a hyperactive immune system, profound haemodynamic disturbances and several metabolic alterations that finally lead to organ dysfunction. These disturbances are triggered by different factors such as bacterial infections, alcoholic hepatitis, gastrointestinal bleeding or hepatitis B virus flare, among others. Because patients with ACLF present high short-term mortality, a prompt recognition is needed to start treatment of the trigger event and specific organ support. Liver transplantation is also feasible in carefully selected patients and should be evaluated.

Mechanisms and treatment approaches for ACLF

Acute-on-chronic liver failure (ACLF) is a life-threatening syndrome characterized by decompensation of cirrhosis, severe systemic inflammation and organ failures. ACLF is frequently triggered by intra- and/or extrahepatic insults, such as bacterial infections, alcohol-related hepatitis or flares of hepatic viruses. The imbalance between systemic inflammation and immune tolerance causes organ failures through the following mechanisms: (i) direct damage of immune cells/mediators; (ii) worsening of circulatory dysfunction resulting in organ hypoperfusion and (iii) metabolic alterations with prioritization of energetic substrates for inflammation and peripheral organ 'energetic crisis'. Currently, the management of ACLF includes the support of organ failures, the identification and treatment of precipitating factors and expedited assessment for liver transplantation (LT). Early LT should be considered in patients with ACLF grade 3, who are unlikely to recover with the available treatments and have a mortality rate > 70% at 28 days. However, the selection of transplant candidates and their prioritization on the LT waiting list need standardization. Future challenges in the ACLF field include a better understanding of pathophysiological mechanisms leading to inflammation and organ failures, the development of specific treatments for the disease and personalized treatment approaches. Herein, we reviewed the current knowledge and future perspectives on mechanisms and treatment of ACLF.

Novel treatment of acute and acute-on-chronic liver failure: Interleukin-22

Acute liver failure (ALF) is a life-threatening medical condition, characterized by rapidly progressive hepatic dysfunction, coagulopathy and hepatic encephalopathy in patients without chronic liver disease, while acute-on-chronic liver failure (ACLF) occurs in patients with existing chronic liver disease. ALF and ACLF are often associated with multiple organ failure and a high short-term mortality. In this review, we briefly discuss the causes and pathogenesis of ALF and ACLF, the current options available for the treatment of both deadly maladies and interleukin-22 (IL-22), a novel promising drug that may have great therapeutic potential for ALF and ACLF treatment. IL-22 is a cytokine produced by immune cells but mainly targets epithelial cells including hepatocytes. IL-22 has been shown to protect against organ damage and reduce bacterial infection in many preclinical models and several clinical trials including alcohol-associated hepatitis. The potential application of IL-22 for the treatment of ALF and ACLF is also elaborated.

Recompensation features and prognosis in hepatitis B virus-related acute-on-chronic liver failure patients

OBJECTIVE

This study aimed to investigate the characteristics and prognosis of recompensation in hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF).

METHODS

A total of 136 patients with HBV-related ACLF were followed up until the end of the study. Patients were categorized into recompensation and non-recompensation groups based on whether recompensation occurred in the first year. The survival rate and incidence of recompensation were calculated using the Kaplan-Meier method.

RESULTS

According to the BAVENO VII consensus criteria, 56 (41.18%) of these patients with ACLF regained recompensation in the 1-year follow-up. The recompensated group had less severe liver damage, higher alpha-fetoprotein, lower age, and lower model for end-stage liver disease score. Specifically, in terms of complications, the recompensated group showed a lower incidence compared with the non-recompensated group ( P  < 0.05). The 3-, 6-, 12-, 36-, and 60-month cumulative survival rates of ACLF were 44.9, 43.4, 43.4, 40.4, and 40.4% respectively. Among the patients who survived beyond 90 days, 57/61 (93.44%) patients showed recompensation of ACLF (with one patient recovering to recompensation after more than 1 year of follow-up), the 3-, 6-, 12-, and 24-month cumulative recompensation rates were 56.5, 90.9, 94.6, and 97.3%, respectively. Among the 57 patients with recompensation of ACLF, 87.7% maintained a stable condition, and 10.5% were diagnosed with hepatocellular carcinoma (HCC).

CONCLUSION

Milder necrosis, less inflammation, and more vigorous hepatic regeneration are conducive to recompensation and a better long-term prognosis in ACLF. However, the occurrence of HCC cannot be avoided and regular monitoring is necessary in the recompensation of ACLF.

Prognosis algorithms for acute decompensation of cirrhosis and ACLF

Accurate prediction of survival in patients with cirrhosis is crucial, as patients who are unlikely to survive in the short-term need to be oriented to liver transplantation and to novel therapeutic approaches. Patients with acute decompensation of cirrhosis without or with organ dysfunction/failure, the so-called acute-on-chronic liver failure (ACLF), have a particularly high short-term mortality. Recognizing the specificity of this clinical situation, dedicated classifications and scores have been developed over the last 15 years, including variables (e.g. organ failures and systemic inflammation) not part of the formerly available cirrhosis severity scores, namely Child-Pugh score or MELD. For patients with acute decompensation of cirrhosis, it led to the development of a dedicated score, the Clif-C-AD score, independently validated. For more severe patients, three different scoring systems have been proposed, by European, Asian and North American societies namely Clif-C-ACLF, AARC score and NASCELD-ACLF respectively. These scores have been validated, and are widely used across the world. The differences and similarities between these scores, as well as their validation and limitations are discussed here. Even if these scores and classifications have been a step forward in favouring homogeneity between studies, and in helping making decisions for individual patients, their predictive value for mortality can still be improved as their area under the ROC curve does not exceed .8. Novel scores including biomarkers reflecting the pathophysiology of acute decompensation of cirrhosis might help reach that goal.

Definition, diagnosis and epidemiology of acute-on-chronic liver failure

This narrative review addresses the definition of acute-on-chronic liver failure, a condition associated with high short-term mortality in patients with chronic liver disease and/or cirrhosis. We provide two major points of view: the East and the West perspective. Both definitions vary regarding the underlying patient population and organ failure(s) definition. Nevertheless, all the definitions have their clinical utility: from the core concept of having the "liver" as a conditio sine qua non, the syndrome cannot exist (Asian Pacific Association for the Study of the Liver); a data-driven, robust definition (European Association for the Study of the Liver); a bedside tool that can quickly identify patients at high risk of dying (North American Consortium for the Study of End-stage Liver Disease [NACSELD]). In each section, we provide the overall definitions, the criteria of organ failure(s), and some epidemiological data illustrating how these apply in each area of the world.

Drug-Induced Liver Injury in Patients With Chronic Liver Disease

OBJECTIVE

Drug-induced liver injury (DILI) is a global problem and can develop from exposure to prescription or over-the-counter medications as well as herbal and dietary supplements. The diagnosis of DILI is clinically challenging, and liver injury can be severe leading to liver failure, death, or liver transplantation. Patients with underlying chronic liver diseases (CLD) may be at increased risk for DILI, which is associated with factors related to drug or liver disease.

METHODS

This review summarises current knowledge on the risk and outcomes of DILI in patients with CLD.

RESULTS

Patients with CLD may be at an increased risk for DILI. Additionally patients with underlying CLD are at risk for more severe liver injury and worse outcomes after DILI.

DISCUSSION

The risk for and poor outcomes from DILI are accentuated in patients with CLD and potentially leading to the worst-case scenario of acute-on-chronic liver failure. We highlight the key observations on DILI with a broad range of underlying liver diseases and the high-DILI risk agents implicated in those populations.

Omics in acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a critical syndrome that develops in patients with chronic liver disease and is characterized by acute decompensation, single- or multiple-organ failure and high short-term mortality. Over the past few decades, ACLF has been progressively recognized as an independent clinical entity, and several criteria and prognostic scores have been proposed and validated by different scientific societies. However, controversies still exist in some aspects across regions, which mainly involve whether the definition of underlying liver diseases should include cirrhosis and non-cirrhosis. The pathophysiology of ACLF is complicated and remains unclear, although accumulating evidence based on different aetiologies of ACLF shows that it is closely associated with intense systemic inflammation and immune-metabolism disorder, which result in mitochondrial dysfunction and microenvironment imbalance, leading to disease development and organ failure. In-depth insight into the biological pathways involved in the mechanisms of ACLF and potential mechanistic targets that improve patient survival still needs to be investigated. Omics-based analytical techniques, including genomics, transcriptomics, proteomics, metabolomics and microbiomes, have developed rapidly and can offer novel insights into the essential pathophysiologic process of ACLF. In this paper, we briefly reviewed and summarized the current knowledge and recent advances in the definitions, criteria and prognostic assessments of ACLF; we also described the omics techniques and how omics-based analyses have been applied to investigate and characterize the biological mechanisms of ACLF and identify potential predictive biomarkers and therapeutic targets for ACLF. We also outline the challenges, future directions and limitations presented by omics-based analyses in clinical ACLF research.

Dynamic skeletal muscle loss and its predictive role on 90-day mortality in patients with acute-on-chronic liver failure

Background

Low skeletal muscle mass is an independent risk factor for increased mortality in patients with acute-on-chronic liver failure (ACLF). However, no study has evaluated the temporal changes in muscle mass during the course of ACLF. Therefore, this study aimed to investigate the dynamic changes in muscle mass and their prognostic role in patients with ACLF.

Methods

A retrospective analysis was conducted on consecutive patients with ACLF who underwent two or more abdominal computed tomography examinations within 90 days of admission. The percentage change rates of the skeletal muscle index at the third lumbar vertebra (L3-SMI) were calculated as (L3-SMIfinal - L3-SMIinitial)/(L3-SMIinitial) × 100%.

Results

A total of 154 patients with ACLF were included. During the course of ACLF, the percentage change rates of L3-SMI at 2-7, 8-14, 15-30, 31-60, and 61-90 days were - 0.83 ± 4.43, -3.76 ± 4.40, -7.30 ± 5.89, -10.10 ± 7.45, and - 5.53 ± 9.26, respectively. Significant reductions in L3-SMI were noted in patients with severe conditions compared to other patients at 2-7 days and 15-30 days. Moreover, the rate of decrease in L3-SMI in patients with a lower respiratory quotient (RQ) was significantly greater than that in patients with a normal RQ at 2-7 days and 15-30 days. Additionally, high muscle loss (HR 2.059; 95% CI 1.122-3.780, p = 0.020), rather than pre-existing sarcopenia (HR 1.430; 95% CI 0.724-2.826, p = 0.303) at baseline, was independently associated with 90-day mortality.

Conclusion

Deterioration in muscle mass is associated with disease severity and poor nutritional status and serves as a more effective predictor of adverse short-term outcomes in patients with ACLF. These findings underscore the importance of dynamic evaluation of muscle loss and emphasize the necessity of reversing muscle loss in patients with ACLF.

Prognostic factors for mortality in patients with acute-on-chronic liver failure

OBJECTIVE

The aim is to explore significant prognostic factors for 90-day mortality in patients with acute-on-chronic liver failure (ACLF) and assist clinicians in the early identification of critically ill ACLF patients.

METHODS

A retrospective analysis was conducted on 288 ACLF patients, who were classified into survivors (n = 187) and nonsurvivors (n = 101) based on 90-day outcomes. Multivariate stepwise logistic regression analyses were employed to identify significant prognostic factors and construct a novel prognostic model, the AHUCTPI. The model's performance was assessed and the internal validation was performed. Additionally, the influence of dynamic changes in laboratory markers on 90-day mortality was examined.

RESULTS

Independent risk factors for 90-day mortality included age ≥45 years, presence of hepatic encephalopathy (HE), and upper gastrointestinal bleeding (UGB) during hospitalization, imaging-confirmed cirrhosis at admission, elevated baseline total bilirubin (TBIL), reduced baseline platelet-to-neutrophil ratio (PNR), and elevated baseline international normalized ratio (INR) (P < 0.05 for all). The AHUCTPI model's formula is as follows: Logit (p) = -10.019 + 1.808 × age (1 if ≥45 years, 0 if <45 years) + 1.048 × HE (1 if present, 0 if absent) + 1.721 × UGB (1 if present, 0 if absent) + 1.362 × cirrhosis (1 if present, 0 if absent) + 0.008 × TBIL (μmol/L) - 0.039 × PNR + 1.963 × INR. The AUHCTPI model demonstrated superior predictive accuracy compared with the MELD (Model for End-Stage Liver Disease) score, with the area under the receiver operating characteristic curve values of 0.914 and 0.739, respectively, and calibration curves closely approximating the ideal curve.

CONCLUSION

ACLF is a complex, dynamic syndrome. Age, HE, and UGB during hospitalization, imaging-diagnosed cirrhosis at admission, baseline TBIL, PNR, and INR were significant predictors for 90-day mortality in ACLF patients, and the AHUCTPI model provides excellent calibration and discrimination. Dynamic monitoring of laboratory trends enhances prognostic accuracy and supports timely clinical decision-making.

Integrative anticoagulation of nafamostat mesylate in double plasma molecular adsorption system plus sequential half-dose plasmapheresis for patients with liver failure: a randomised controlled trial protocol

INTRODUCTION

Nafamostat mesylate (NM) is widely recognised as a premier anticoagulant, especially in Japan and Korea. However, it has not yet been used as an anticoagulant in double plasma molecular adsorption system (DPMAS) plus sequential half-dose plasmapheresis (PE) therapy. This study aims to comprehensively evaluate the safety and efficacy of NM-integrated anticoagulation during DPMAS plus sequential half-dose PE therapy for patients with liver failure.

METHODS AND ANALYSIS

A two-arm, open-label, parallel, randomised controlled trial involving 132 patients with liver failure will be conducted in China. Eligible participants will be randomly allocated to either the nafamostat mesylate integrative anticoagulation group or the heparin integrative anticoagulation group, employing a central randomisation system at a 1:1 ratio throughout the course of DPMAS plus sequential half-dose PE therapy. The primary outcome includes the number of successfully completed DPMAS plus sequential half-dose PE therapy. The secondary outcomes include liver function indicators, extracorporeal circulation pressures, coagulation function parameters, all-cause mortality rates and survival rates. Clinical safety will be assessed by analysis of the number of bleeding events, the number of clotting events and adverse events. Outcome analyses will be performed on both the intention-to-treat population, which includes all patients randomised, and the per-protocol population, which includes eligible patients who adhere to the planned treatment and follow-ups.

ETHICS AND DISSEMINATION

The trial protocol was approved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University (approval number (2022)860). During the protocol revision process, all changes were reexamined and reapproved by the Biomedical Research Ethics Committee of West China Hospital of Sichuan University. The results will be presented at national and international conferences and published in peer-reviewed journals.

TRIAL REGISTRATION NUMBER

ChiCTR2200064725.

Predictors for Invasive Pulmonary Aspergillosis in Acute-on-Chronic Liver Failure Patients: A Retrospective Study

Introduction

Acute-on-chronic liver failure (ACLF) is a severe syndrome that manifests as acute liver function deterioration and organ failure. Coinfection with invasive pulmonary aspergillosis (IPA) in ACLF patients is characterized by high mortality and increasing morbidity. The aim of this study was to explore the early warning factors and prognosis of ACLF patients with IPA coinfection.

Methods

In this retrospective study, we collected clinical, biochemical, and microbiological data from patients with ACLF and IPA from May 2019 to May 2023. Univariable and multivariate analyses were used to identify independent risk factors for IPA in ACLF patients. Moreover, the area under the curve (AUC) and decision curve analysis (DCA) were used to evaluate the model performance.

Results

A total of 438 patients with ACLF were enrolled, 408 (93.2%) non-IPA patients and 30 IPA (6.8%) including 29 probable cases and one proven case. The 28-day case fatality rate (56.7% vs 29.4%) was higher in ACLF patients with IPA than in ACLF patients without IPA, but without statistical difference. Multivariate analysis revealed that early warning factors for IPA coinfection in ACLF patients included nausea (p = 0.010), expectoration (p < 0.001), bacterial and fungal infections (p < 0.001), corticosteroid use (p = 0.037), surgery (p = 0.081), haemoptysis (p = 0.015) and increased leukocyte counts (p = 0.010). The AUC was 0.934 (p < 0.001), and DCA verified the validity and clinical effectiveness of our model.

Conclusion

These findings provide valuable insights for clinicians in the early diagnosis of IPA in ACLF patients and may facilitate timely intervention and treatment.