Acute-on-chronic liver failure: concept, natural history, and prognosis. Curr Opin Crit Care. 2011;17:165-169. [PMID: 21326095 DOI: 10.1097/mcc.0b013e328344b42d]

The Association of Age and Liver Transplant Outcomes in Patients With Acute-On-Chronic Liver Failure

INTRODUCTION

To explore the role of age at listing on outcomes for patients with acute-on-chronic liver failure (ACLF) awaiting liver transplantation (LT).

MATERIALS AND METHODS

We assessed adult candidates listed for LT in the Scientific Registry of Transplant Recipients database from January 1, 2007 to June 30, 2018. Patients were divided into four groups based on age at listing: I (≤34), II (35-49), III (50-64), and IV (≥65). The ACLF grade was estimated (est-ACLF), and intent-to-treat survival, overall survival (OS), as well as potential predictors for OS was evaluated.

RESULTS

Est-ACLF-3 was associated with a higher 30-d cumulative dropout rate and inferior intent-to-treat survival across age groups. No difference was observed in OS among ACLF grades in group I, but significantly inferior OS was observed in higher ACLF grades in groups II-IV. Multivariate analysis showed age (P < 0.001, ref. group I; hazard ratio 0.995 for group II, P = 0.936; 1.196 for group III, P = 0.002; 1.651 for group IV, P < 0.001) and est-ACLF grade (P < 0.001, ref. est-ACLF-0; 1.214 for est-ACLF-1, P < 0.001; 1.246 for est-ACLF-2, P < 0.001; 1.578 for est-ACLF-3, P < 0.001) were independent predictors for OS. Generalized additive model showed different association between age and OS among different ACLF grades.

CONCLUSIONS

Young patients with high ACLF grades could achieve similar OS compared with those with low grades. Elderly patients with higher ACLF grades were associated with inferior outcomes after LT.

The value of presepsin and procalcitonin as prognostic factors for mortality in patients with alcoholic liver cirrhosis and acute on chronic liver failure

Background: Acute on chronic liver failure (ACLF) is typically characterized by a rapid progression of liver failure in patients with liver cirrhosis and it is triggered by a precipitant factor, usually a bacterial infection (BI). Considering the low accuracy of the inflammation biomarkers in liver cirrhosis, presepsin and procalcitonin have demonstrated a good diagnostic performance for BI. Understanding the key prognostic factors that influence patient outcomes can significantly impact clinical decision-making and improve patient care in ACLF which can lead to lower mortality rates. Aim: To evaluate the prognostic factors associated with 30-day mortality in patients with alcohol-related liver cirrhosis and ACLF. Methods: This retrospective study on 227 patients diagnosed with ACLF and alcohol-related liver cirrhosis analyzed the prognostic role of presepsin and procalcitonin serum levels. Results: The survival analysis according to the grade of ACLF showed that more than 80% of patients with ACLF grade 1 survived after 30 days, with a mean estimated time of death of 29 ±0.44 days (95 % CI: 28.17-29.92) compared to ACLF grade 2 (24.9±1.064 days; 95 % CI: 22.82-26.99) and ACLF grade 3 (21.05±1.17 days; 95 % CI: 18.75-23.34), with a mean overall survival on entire cohort of 25.69±0.52 days (95 % CI: 24.65-26.73). Presepsin (OR: 4.008, CI 95:3.130-6.456, p=0.001) and procalcitonin (OR: 3.666, CI 95:2.312-5.813, p=0.001) were the most significant factors associated with 30-day mortality. In ACLF grade 2, presepsin provides a better prediction of mortality at the cutoff value of 1050 pg/mL (Sensitivity 72%, Specificity 69%) than procalcitonin (AUC=0.727 95% CI 0.594-0.860, p<0.002) whereas in ACLF grade 3, a cutoff of 1450 pg/mL (Sensitivity 89%, Specificity 91%) presepsin had a more significant accuracy of mortality prediction (AUC=0.93 95% CI 0.81-0.99, p<0.001) than procalcitonin (AUC=0.731 95% CI 0.655-0.807, p<0.001). Conclusion: ACLF is associated with a high mortality rate and the risk of death increases with the grade of ACLF. Presepsin and procalcitonin serum levels are good prognostic factors for 30-day mortality and should be used in clinical practice to stratify the risk and provide and early and efficient treatment in patients with ACLF.

Alpha-fetoprotein and APRI as predictive markers for patients with Type C hepatitis B-related acute-on-chronic liver failure: a retrospective study

BACKGROUND

Type C hepatitis B-related acute-on-chronic liver failure (HBV-ACLF), which is based on decompensated cirrhosis, has different laboratory tests, precipitating events, organ failure and clinical outcomes. The predictors of prognosis for type C HBV-ACLF patients are different from those for other subgroups. This study aimed to construct a novel, short-term prognostic score that applied serological indicators of hepatic regeneration and noninvasive assessment of liver fibrosis to predict outcomes in patients with type C HBV-ACLF.

METHOD

Patients with type C HBV-ACLF were observed for 90 days. Demographic information, clinical examination, and laboratory test results of the enrolled patients were collected. Univariate and multivariate logistic regression were performed to identify independent prognostic factors and develop a novel prognostic scoring system. A receiver operating characteristic (ROC) curve was used to analyse the performance of the model.

RESULTS

A total of 224 patients with type C HBV-ACLF were finally included. The overall survival rate within 90 days was 47.77%. Age, total bilirubin (TBil), international normalized ratio (INR), alpha-fetoprotein (AFP), white blood cell (WBC), serum sodium (Na), and aspartate aminotransferase/platelet ratio index (APRI) were found to be independent prognostic factors. According to the results of the logistic regression analysis, a new prognostic model (named the A3Twin score) was established. The area under the curve (AUC) of the receiver operating characteristic curve (ROC) was 0.851 [95% CI (0.801-0.901)], the sensitivity was 78.8%, and the specificity was 71.8%, which were significantly higher than those of the MELD, IMELD, MELD-Na, TACIA and COSSH-ACLF II scores (all P < 0.001). Patients with lower A3Twin scores (<-9.07) survived longer.

CONCLUSIONS

A new prognostic scoring system for patients with type C HBV-ACLF based on seven routine indices was established in our study and can accurately predict short-term mortality and might be used to guide clinical management.

Outcome Predictors of Acute-on-Chronic Liver Failure: A Narrative Review

Complications of acute-on-chronic liver failure (ACLF) include increased short-term mortality. Extrahepatic organ failures result from chronic liver disease and acute hepatic injury. This combination characterizes end-stage liver disease. Its rapid progression makes it challenging for hepatologists and intensivists to treat. The varied definitions of this condition lead to varied clinical presentations. Hepatic or extrahepatic failures are more prevalent in chronic hepatitis B or cirrhosis patients who receive an additional injury. Numerous intensity parameters and prognosis ratings, including those for hepatitis B virus (HBV), have been developed and verified for various patients and causes of the disease. Liver regeneration, liver transplantation (LT), or antiviral therapy for HBV-related ACLF are the main treatment aims for various organ failures. LT is the best treatment for HBV-ACLF. In some HBV-related ACLF patients, nucleos(t)ide analogs and artificial liver assistance may enhance survival. Combining epidemiological and clinical studies, this review updates our understanding of HBV-ACLF's definition, diagnosis, epidemiology, etiology, therapy, and prognosis.

The clinical courses of HBV-related acute-on-chronic liver failure and a multi-state model to predict disease evolution

BACKGROUND AND AIMS

Acute-on-chronic liver failure (ACLF) is a highly dynamic syndrome. The objective of this study was to delineate the clinical course of patients with HBV-ACLF and to develop a model to estimate the temporal evolution of disease severity.

METHODS

We enrolled eligible patients from 2 large, multicenter prospective cohorts. The ACLF grade, organ failures, and outcomes were assessed at multiple time points (days 1/4/7/14/21/28). Probabilities for ACLF transitions between these disease states and to death within 28 days were calculated using a multi-state model that used baseline information and updated ACLF status. The model was validated in independent patients.

RESULTS

Among all the 445 patients with HBV-ACLF, 76 represented disease progression, 195 had a stable or fluctuating course, 8 with improvement, and the remaining 166 with resolution within 28-day follow-up. New coagulation (63.64%) or renal failure (45.45%) was frequently observed during early progression. Patients with disease progression had a higher incidence of new episodes of ascites [10 (13.16%) vs. 22 (5.96%), p = 0.027] and HE [13(17.11%) vs. 21 (5.69%), p = 0.001], and a significant increase in white blood cell count. The multi-state model represented dynamic areas under the receiver operating characteristic curves ranging from 0.71 to 0.84 for predicting all ACLF states and death at 4, 7, 14, 21, and 28 days post-enrollment and from 0.73 to 0.94 for predicting death alone, performing better than traditional prognostic scores.

CONCLUSIONS

HBV-ACLF is a highly dynamic syndrome with reversibility. The multi-state model is a tool to estimate the temporal evolution of disease severity, which may inform clinical decisions on treatment.

The Effect of Molecular Adsorbent Recirculating System in Patients With Liver Failure: A Case Series of 44 Patients

BACKGROUND

Liver failure is associated with a high mortality rate, with many patients requiring transplant for definitive treatment. The Molecular Adsorbent Recirculating System (MARS) is a nonbiologic system that provides extracorporeal support. Literature on MARS therapy is mixed: outcomes support MARS therapy for patients with isolated acute liver failure, but data on patients with chronic disease is varied. Several case studies report success using MARS as a bridging treatment for patients awaiting transplant. The purpose of this case series is to present the outcomes of 44 patients who underwent MARS therapy for liver failure, 19 of whom used MARS therapy as a bridging therapy to transplant.

METHODS

This study retrospectively identified 44 patients who underwent MARS therapy for liver failure at Mayo Clinic, Jacksonville, between January 2014 and April 2021. Variables of interest included changes in laboratory markers of hepatic functioning, number and length of MARS therapy sessions, transplantation status, and mortality.

RESULTS

Following MARS therapy, there were improvements in mean serum bilirubin, ammonia, urea, creatinine, International Normalized Ratio, alanine aminotransferase, and aspartate aminotransferase levels. Twenty-seven patients (61.36%) survived the hospital stay; 17 (38.63%) died in the hospital. The majority of surviving patients (n = 19; 73.07%) received liver transplant. Six did not require transplant (22.22%). All but 1 patient who received MARS as a bridging treatment to transplant survived the follow-up period (n = 18; 94.74%).

CONCLUSIONS

Outcomes of these 44 cases suggest that MARS improves liver failure-associated laboratory parameters and may be effective therapy as a bridge to liver transplant.

Efficacy of Granulocyte Colony-Stimulating Factor in Acute on Chronic Liver Failure: A Systematic Review and Survival Meta-Analysis

BACKGROUND

Acute-on-chronic liver failure (ACLF) mostly occurs when there is an acute insult to the liver in patients with pre-existing liver disease, and it is characterized by a high mortality rate. Various therapeutic approaches have been used thus far, with orthotopic liver transplantation being the only definitive cure. Clinical trials and meta-analyses have investigated the use of granulocyte colony-stimulating factor (G-CSF) to mobilize bone marrow-derived stem cells. Some studies have suggested that G-CSF may have a significant role in the management and survival of patients with ACLF. However, the results are conflicting, and the efficacy of G-CSF still needs to be confirmed.

AIM

The aim was to assess the efficacy of G-CSF in patients with ACLF.

METHODS

Electronic databases were searched until May 2023 for randomized controlled trials investigating the use of G-CSF in adult patients with ACLF. Outcome measures were the effects of G-CSF on overall survival, changes in liver disease severity scores, complications of cirrhosis, other G-CSF-related adverse effects, and all-cause mortality. The study's protocol has been registered with Prospero (CRD42023420273).

RESULTS

Five double-blind randomized controlled trials involving a total of 421 participants met the inclusion criteria. The use of G-CSF demonstrated a significant effect on overall survival (HR 0.63, 95% CI 0.41 to 0.95, and I2 48%), leading to a decreased mortality (LogOR-0.97, 95% CI -1.57 to -0.37, and I2 37.6%) and improved Model for End-Stage Liver Disease (MELD) scores (SMD -0.87, 95% CI -1.62 to -0.13, and I2 87.3%). There was no correlation between the improvement of the Child-Pugh score and the use of G-CSF(SMD -2.47, 95% CI -5.78 to 0.83, and I2 98.1%). The incidence of complications of cirrhosis did not decrease significantly with G-CSF treatment (rate ratio 0.51, 95% CI 0.26 to 1.01, and I2 90%). A qualitative synthesis showed that the use of G-CSF is safe.

CONCLUSIONS

The administration of G-CSF has demonstrated a positive impact on overall survival, liver function, and the MELD score. The presence of heterogeneity in the included studies prohibits conclusive recommendations.

Acute on Chronic Liver Failure in Patients with Alcohol-Associated Hepatitis: A Review

Acute on chronic liver failure (ACLF) is a unique disease process associated with significant short-term mortality wherein patients with either chronic liver disease or cirrhosis suffer rapid decompensation in hepatic function accompanied by extrahepatic organ failures. Alcohol-associated hepatitis (AH) is a common precipitant of ACLF and has been shown to uniquely affect the pathophysiology of systemic and hepatic immune responses in patients with ACLF. Treatment of AH-associated ACLF includes supportive measures as well as treatment directed at AH; however, AH-directed therapies unfortunately remain limited and are of suboptimal efficacy.

Acute-on-chronic liver failure is independently associated with higher mortality for cirrhotic patients with acute esophageal variceal hemorrhage: Retrospective cohort study

BACKGROUND

Acute esophageal variceal hemorrhage (AEVH) is a common complication of cirrhosis and might precipitate multi-organ failure, causing acute-on-chronic liver failure (ACLF).

AIM

To analyze if the presence and grading of ACLF as defined by European Society for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) is able to predict mortality in cirrhotic patients presenting AEVH.

METHODS

Retrospective cohort study executed in Hospital Geral de Caxias do Sul. Data from medical records from 2010 to 2016 were obtained by searching the hospital electronic database for patients who received terlipressin. Medical records were reviewed in order to determine the diagnosis of cirrhosis and AEVH, including 97 patients. Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis.

RESULTS

All- cause mortality for AEVH patients was 36%, 40.2% and 49.4% for 30-, 90- and 365-day, respectively. The prevalence of ACLF was 41.3%. Of these, 35% grade 1, 50% grade 2 and 15% grade 3. In multivariate analysis, the non-use of non-selective beta-blockers, presence and higher grading of ACLF and higher Model for End-Stage Liver Disease scores were independently associated with higher mortality for 30-day with the addition of higher Child-Pugh scores for 90-day period.

CONCLUSION

Presence and grading of ACLF according to the EASL-CLIF criteria was independently associated with higher 30- and 90-day mortality in cirrhotic patients admitted due to AEVH.

Landscapes of gut microbiome and bile acid signatures and their interaction in HBV-associated acute-on-chronic liver failure

Introduction

Submassive hepatic necrosis (SMHN, defined as necrosis of 15-90% of the entire liver on explant) is a likely characteristic pathological feature of ACLF in patients with hepatitis B cirrhosis. We aimed to comprehensively explore microbiome and bile acids patterns across enterhepatic circulation and build well-performing machine learning models to predict SMHN status.

Methods

Based on the presence or absence of SMHN, 17 patients with HBV-related end-stage liver disease who received liver transplantation were eligible for inclusion. Serum, portal venous blood, and stool samples were collected for comparing differences of BA spectra and gut microbiome and their interactions. We adopted the random forest algorithm with recursive feature elimination (RF-RFE) to predict SMHN status.

Results

By comparing total BA spectrum between SMHN (-) and SMHN (+) patients, significant changes were detected only in fecal (P = 0.015). Compared with the SMHN (+) group, the SMHN (-) group showed that UDCA, 7-KLCA, 3-DHCA, 7-KDCA, ISOLCA and α-MCA in feces, r-MCA, 7-KLCA and 7-KDCA in serum, γ-MCA and 7-KLCA in portal vein were enriched, and TUDCA in feces was depleted. PCoA analysis showed significantly distinct overall microbial composition in two groups (P = 0.026). Co-abundance analysis showed that bacterial species formed strong and broad relationships with BAs. Among them, Parabacteroides distasonis had the highest node degree. We further identified a combinatorial marker panel with a high AUC of 0.92.

Discussion

Our study demonstrated the changes and interactions of intestinal microbiome and BAs during enterohepatic circulation in ACLF patients with SMHN. In addition, we identified a combinatorial marker panel as non-invasive biomarkers to distinguish the SMHN status with high AUC.

Mortality scoring systems for liver transplant recipients: before and after model for end-stage liver disease score

The mortality scoring systems for patients with end-stage liver disease have evolved from the Child-Turcotte-Pugh score to the model for end-stage liver disease (MELD) score, affecting the wait list for liver allocation. There are inherent weaknesses in the MELD score, with the gradual decline in its accuracy owing to changes in patient demographics or treatment options. Continuous refinement of the MELD score is in progress; however, both advantages and disadvantages exist. Recently, attempts have been made to introduce artificial intelligence into mortality prediction; however, many challenges must still be overcome. More research is needed to improve the accuracy of mortality prediction in liver transplant recipients.

CLIF-SOFA and CLIF-C scores for the prognostication of acute-on-chronic liver failure and acute decompensation of cirrhosis: A systematic review

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by decompensation in individuals with chronic liver disease, generally secondary to one or more extra-hepatic organ failures, implying an elevated mortality rate. Acute decompensation (AD) is the term used for one or more significant consequences of liver disease in a short time and is the most common reason for hospital admission in cirrhotic patients. The European Association for the Study of Liver-Chronic-Liver Failure (EASL-CLIF) Group modified the intensive care Sequential Organ Failure Assessment score into CLIF-SOFA, which detects the presence of ACLF in patients with or without AD, classifying it into three grades.

AIM

To investigate the role of the EASL-CLIF definition for ACLF and the ability of CLIF-SOFA, CLIF-C ACLF, and CLIF-C AD scores for prognosticating ACLF or AD.

METHODS

This study is a literature review using a standardized search method, conducted using the steps following the guidelines for reporting systematic reviews set out by the PRISMA statement. For specific keywords, relevant articles were found by searching PubMed, ScienceDirect, and BioMed Central-BMC. The databases were searched using the search terms by one reviewer, and a list of potentially eligible studies was generated based on the titles and abstracts screened. The data were then extracted and assessed on the basis of the Reference Citation Analysis (https://www.referencecitationanalysis.com/).

RESULTS

Most of the included studies used the EASL-CLIF definition for ACLF to identify cirrhotic patients with a significant risk of short-term mortality. The primary outcome in all reviewed studies was mortality. Most of the study findings were based on an area under the receiver operating characteristic curve (AUROC) analysis, which revealed that CLIF-SOFA, CLIF-C ACLF, and CLIF-C AD scores were preferable to other models predicting 28-d mortality. Their AUROC scores were higher and able to predict all-cause mortality at 90, 180, and 365 d. A total of 50 articles were included in this study, which found that the CLIF-SOFA, CLIF-C ACLF and CLIF-C AD scores in more than half of the articles were able to predict short-term and long-term mortality in patients with either ACLF or AD.

CONCLUSION

CLIF-SOFA score surpasses other models in predicting mortality in ACLF patients, especially in the short-term. CLIF-SOFA, CLIF-C ACLF, and CLIF-C AD are accurate short-term and long-term mortality prognosticating scores.

Rate of Successful Extubation in Mechanically Ventilated Patients with Cirrhosis and Hepatic Coma

BACKGROUND

The prognosis of critically ill patients with cirrhosis who require mechanical ventilation is guarded. Data are lacking for the optimal therapeutic approach to hepatic encephalopathy (HE) in the ventilated patient.

METHODS

Retrospective cohort analysis of 314 encounters (298 patients) with cirrhosis who underwent mechanical ventilation in a medical ICU and were ordered at least 1 dose of lactulose. Hazard of extubation alive was determined using a competing risk model. Primary exposures were HE therapy (lactulose and rifaximin) which were adjusted for the indication for ventilation (HE, procedures, respiratory failure), age, MELD-Na, and compensation status.

RESULTS

Indications for ventilation were 22.3% for grade 4 HE, 29.9% for procedures, and 47.8% for respiratory or cardiovascular failure. Median length of intubation was 2.63 days; death rate on ventilator was 31.2%. Relative to intubation for procedure, hazard of extubation for intubation for HE was 0.34 (95% confidence interval (CI): 0.22-0.52) and 0.33 (CI: 0.23-0.47) for respiratory failure. Hazard of extubation for rifaximin administration within 24-h after intubation was significant at 1.74 (1.21-2.50). Lactulose dosing was not significant for hazard of extubation.

DISCUSSION

Mortality is high for all patients with cirrhosis requiring mechanical ventilation, including those intubated for grade 4 HE. Efforts to optimize the odds of successful extubation are urgently needed. Our findings suggest improved incidence of extubation associated with rifaximin administration in the first 24-h after intubation. Prospective, multi-center data to confirm these findings in this vulnerable population are warranted.

Serum Interleukins as Potential Prognostic Biomarkers in HBV-Related Acute-on-Chronic Liver Failure

Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is relatively common in China and has complex pathogenesis, difficult clinical treatment, and poor prognosis. Immune status is an important factor affecting ACLF prognosis. Interleukins are a family of secreted lymphocyte factors that interact with a host of cell types including immune cells. These signaling molecules play important roles in transmitting information; regulating immune cells; mediating the activation, proliferation, and differentiation of T and B cells; and modulating inflammatory responses. Many studies have investigated the correlation between interleukin expression and the prognosis of HBV-ACLF. This review focuses on the potential use of interleukins as prognostic biomarkers in HBV-ACLF. References were mainly identified through PubMed and CNKI search, including relevant studies published until December 2021. We have summarized reports of several promising diagnostic interleukin biomarkers that predict susceptibility to HBV-ACLF. The use of biomarkers to understand early prognosis can help devise different therapeutic measures and improve patient survival. Ongoing research on prognostic biomarkers of HBV-ACLF is promising, and future preclinical and clinical studies are warranted.

A review on acute, severe hepatitis of unknown origin in children: A call for concern

Hepatitis is defined as the inflammatory reaction of the liver parenchyma. It is either acute, which resolves within six months or may be chronic. An outbreak of severe, acute hepatitis of unknown origin in children was reported in nearly all World Health Organisation (WHO) regions except in the Africa. As per the recent update on the 26th of May, approximately 650 cases have met the WHO's probable criteria. While some are yet to be confirmed, the WHO warns that the figure may be underestimating the real situation. The observed clinical presentation includes outstanding immoderate levels of transaminases, vomiting from the previous presentation, pale/mild stools, and jaundice. So far, the viruses which can cause viral hepatitides, like Hepatitis A, B, C, D, and E, have not been detected in any of the identified cases. Some literature reported human enteric adenovirus type 41F in the majority of cases aged sixteen or younger, with few cases of co-infection with SARS-CoV-2. Currently, only several hypotheses have discussed the causality of the outbreak. However, no consensus has been reached. During this outbreak, it is important to adhere to both hand and body hygiene, general infection and control prevention strategies, and lastly, case presentation matching the criteria of case definition set by the WHO. Said identified cases should be reported to concerned health authorities on an urgent basis and must be kept under proper surveillance.

•

Hepatitis is defined as the inflammatory reaction of the liver parenchyma. It is either acute, which resolves within six months or may be chronic.

•

An outbreak of severe, acute hepatitis of unknown origin in children was reported in nearly all World Health Organisation (WHO) regions except in the Africa.

•

Although extensive research has not been conducted on the rapidly-progressing AHUO in children, current literature has reported human enteric adenovirus type-41F in most cases aged sixteen or younger.

•

Potential confounding coronavirus infection is one of several theories currently being considered in acute non-hepatitis A–E viral hepatitis origin.

•

During this outbreak, it is important to adhere to both hand and body hygiene, general infection and control prevention strategies, and lastly, case presentation matching the criteria of case definition set by the WHO.

Wenyang Huazhuo Tuihuang Formula Inhibits the Th17/Treg Cell Imbalance and Protects against Acute-on-Chronic Liver Failure

OBJECTIVE

Acute-on-chronic liver failure (ACLF) is a group of chronic liver diseases and caused by acute internal and external liver injury. Wenyang Huazhuo Tuihuang (WYHZTH) formula had a good clinical effect on promoting the resolution of jaundice. The aim of this study is to further investigate the mechanism of the WYHZTH formula in the ACLF rat model.

METHODS

The ACLF rat model was constructed by combining human serum albumin with LPS and D-gal. WYHZTH was used to intervene and treat. The cytokines IL-17, IL-23, IL-10, and TGF-β were detected by ELISA and fluorescence-quantitative PCR. Flow cytometry was used to detect the percentage of Th17 and Treg cells in the peripheral blood and liver tissues of each group of rats. The pathological changes in the liver tissue were detected by hematoxylin-eosin staining, immunohistochemistry, and electron microscopy.

RESULTS

Compared with the ACLF group, the WYHZTH formula and Thy significantly decreased the levels of ALT, AST, and CHE in the ACLF group. After drug intervention, apoptosis was significantly reduced. The PCNA expression decreased in the ACLF model group but increased in the WYHZTH or Thy group. Under transmission electron microscope, hepatocytes in the ACLF group showed obvious necrosis. After drug intervention, hepatocyte necrosis was reduced with most of the structure returning to normal.

CONCLUSION

This present study demonstrated that WYHZTH formula may protect against acute-on-chronic liver failure, which may be related to the inhibition of Th17/Treg cell imbalance.

Effects of Inflammation on Hemostasis in Acutely Ill Patients with Liver Disease

Patients with liver diseases are in a rebalanced state of hemostasis, due to simultaneous decline in pro- and anticoagulant factors. This balance seems to remain even in the sickest patients, but is less stable and might destabilize when patients develop disease complications. Patients with acute decompensation of cirrhosis, acute-on-chronic liver failure, or acute liver failure often develop complications associated with changes in the hemostatic system, such as systemic inflammation. Systemic inflammation causes hemostatic alterations by adhesion and aggregation of platelets, release of von Willebrand factor (VWF), enhanced expression of tissue factor, inhibition of natural anticoagulant pathways, and inhibition of fibrinolysis. Laboratory tests of hemostasis in acutely-ill liver patients may indicate a hypocoagulable state (decreased platelet count, prolongations in prothrombin time and activated partial thromboplastin time, decreased fibrinogen levels) due to decreased synthetic liver capacity or consumption, or a hypercoagulable state (increased VWF levels, hypofibrinolysis in global tests). Whether these changes are clinically relevant and should be corrected with antithrombotic drugs or blood products is incompletely understood. Inflammation and activation of coagulation may cause local ischemia, progression of liver disease, and multiorgan failure. Anti-inflammatory treatment in acutely-ill liver patients may be of potential interest to prevent thrombotic or bleeding complications and halt progression of liver disease.

Evidence-based protocol for diagnosis and treatment of hepatorenal syndrome is independently associated with lower mortality

BACKGROUND

Hepatorenal syndrome (HRS) is the deadliest complication of cirrhosis. The purpose of this study is to analyze if the use of a protocol for HRS is associated with higher survival in these patients.

METHODS

An evidence-based protocol for the diagnosis and treatment of HRS was instituted in 2013. Data from medical records from 2010 to 2016 were obtained by searching the hospital database for patients who received terlipressin, in the three years before and after the institution of the protocol. Data were reviewed to confirm the diagnosis of HRS and multiple variables were collected. Liver-specific scores were calculated and a stepwise Cox regression approach was used for univariate and multivariate analysis.

RESULTS

The study included 46 patients, 20 from the pre-protocol period and 26 from the post-protocol period. Respectively, mortality at 30 days, 90 days and 365 days was 75%, 75% and 90% for the pre-protocol period, and 61%, 69% and 80% for the post-protocol period. In the multivariate analysis, an aspartate aminotransferase (AST) of <40U/L, the pre-protocol period and higher Child-Turcotte-Pugh scores were associated with higher 30-day and 90-day mortality. The total mean dose of terlipressin and human albumin used per patient was reduced from 27mg to 22mg and from 236g to 144g, respectively, after the institution of the protocol. This was not associated with higher mortality.

CONCLUSION

The use of an evidence-based protocol for the treatment of HRS translated into a higher survival. The authors suggest that the use of evidence-based protocols for the diagnosis and treatment of HRS could reduce cost and mortality in tertiary hospitals.

ACUTE-ON-CHRONIC LIVER FAILURE IS INDEPENDENTLY ASSOCIATED WITH LOWER SURVIVAL IN PATIENTS WITH SPONTANEOUS BACTERIAL PERITONITIS

BACKGROUND

Spontaneous bacterial peritonitis (SBP) is a decompensation of cirrhosis with an in-hospital mortality ranging from 20% to 40%.

OBJECTIVE

The purpose of this study is to analyze if EASL-CLIF definition of acute-on-chronic liver failure (ACLF) is able to predict mortality in cirrhotic patients with SBP.

METHODS

Historical cohort study conducted in a public tertiary care teaching hospital. Data from medical records from January 2009 to July 2016 were obtained by searching the hospital electronic database for samples of ascites collected in the period. Electronic and physical medical records were analyzed and patients were included if they were over 18-years old, with cirrhosis and an ascites fluid compatible with SBP: 69 patients were included. Liver-specific scores were calculated and Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis.

RESULTS

All cause mortality was 44%, 56.5% and 74% for 28-, 90- and 365-day, respectively. The prevalence of ACLF was 58%. Of these, 65% grade 1, 17.5% grade 2 and 17.5% grade 3. In multivariate analysis, the use of proton-pump inhi-bitors, alanine transaminase lower than 40 U/L, hemoglobin higher than 9 g/dL, absence of ACLF and lower CLIF-SOFA and MELD scores were independently associated with higher survival for both 28- and 90-day interval.

CONCLUSION

The presence of ACLF and higher CLIF-SOFA scores were independently associated with higher 28- and 90-day mortality in cirrhotic patients admitted due to SBP.

Prevalence and outcomes of acute-on-chronic liver failure among cirrhotic patients admitted for an acute decompensation

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a common syndrome that occurs in patients with advanced chronic liver disease. It consists of the rapid failure of various organs and is associated with high short-term mortality. We aim to describe the main features and outcomes of inpatients who developed ACLF and to identify the factors associated with in-hospital and 28-day mortality.

PATIENTS AND METHODS

All patients meeting ACLF criteria with advanced chronic liver disease admitted for decompensation from January 2014 to December 2016 were identified. Clinical and biological data were collected at the time of ACLF diagnosis and at 3-7 days thereafter, as well as in-hospital and 28-day mortality.

RESULTS

Eighty nine out of 354 admission episodes (28%) developed ACLF, which was present at the time of admission in 72% of cases. A precipitating factor was identified in 83% of cases, the most frequent being infection (53%) and gastrointestinal bleeding (19%). In the multivariate regression analysis, the ACLF grade at 3-7 days after diagnosis was predictive of in-hospital mortality and 28-day mortality, and lower creatinine and bilirubin levels at the time of ACLF diagnosis and a precipitating factor other than bacterial infection were associated with ACLF reversion at 3-7 days.

CONCLUSIONS

ACLF is a frequent complication among patients with chronic liver disease admitted for acute decompensations and is associated with a high mortality rate and is related to the number of organs involved. Bacterial infection is the most frequent precipitating factor of ACLF and probably entails a worse prognosis.

Intra-abdominal hypertension and abdominal compartment syndrome in the critically ill liver cirrhotic patient-prevalence and clinical outcomes. A multicentric retrospective cohort study in intensive care

Background

Liver cirrhosis and ascites are risk factors for intra-abdominal hypertension (IAH) and abdominal compartment syndrome (ACS); however, data is scarce. We aimed to determine the prevalence of IAH/ACS in a population of critically ill cirrhotic patients with acute medical illness in intensive care and to assess for risk factors and clinical outcomes.

Methods

This was a multicentric retrospective cohort study including two general ICUs and pooled data from a multicentric study between January 2009 and October 2019.

Results

A total of 9,345 patients were screened, and 95 were included in the analysis. Mean age was 56.7±1.3 years, and 79% were male. Liver cirrhosis etiology included alcohol in 45.3% and alcohol plus hepatitis C virus in 9.5%. Precipitating events included infection in 26% and bleeding in 21% of cases. Mean severity score MELD and SAPS II were 26.2±9.9 and 48.5±15.3, respectively, at ICU admission. The prevalence of IAH and ACS was respectively 82.1% and 23.2% with a mean value of maximum IAP of 16.0±5.7 mmHg and IAH grades: absent 17.9%, I 26.3%, II 33.7%, III 17.9%, and IV 4.2%. Independent risk factors for IAH were alcoholic cirrhosis (p = 0.01), West-Haven score (p = 0.01), and PaO2/FiO2 ratio (p = 0.02); as well as infection (p = 0.048) for ACS. Overall, 28-day mortality was 52.6% associated with higher IAP and ACS, and independent risk factors were MELD (p = 0.001), white blood cell count (p = 0.03), PaO2/FiO2 ratio (p = 0.03), and lactate concentration (p = 0.04) at ICU admission.

Conclusions

This study demonstrates a very high prevalence of IAH/ACS in the critically ill cirrhotic patient in intensive care. Increased IAP and ACS were associated with severity of disease and adverse outcomes and independent risk factors for IAH were alcoholic cirrhosis, hepatic encephalopathy and PO2/FiO2 ratio, as well as infection for ACS. Early diagnosis, prevention, and treatment of IAH/ACS might improve outcome in critically ill cirrhotic patients.

World Gastroenterology Organisation classification and a new type-based prognostic model for hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND

The acute-on-chronic liver failure (ACLF) classification, proposed by the World Gastroenterology Organisation (WGO), attempts to cover all ACLF patients diagnosed in the East and West. This study aimed to explore and establish a prognostic model based on this classification.

METHODS

A total of 1159 hepatitis B virus-ACLF patients, enrolled with 90-day follow-up data, were divided into three groups (type A, B, and C) according to WGO ACLF classification and analyzed. A model of ACLF prognosis based on type (MAPT) was developed in a derivation cohort (n = 566); its reproducibility was tested in a validation cohort (n = 593).

RESULTS

A significant difference in 90-day mortality among the three groups was observed (31.1%, type A; 40.9%, type B; 61.4%, type C, P < 0.001). ACLF type was determined to be an independent risk factor of 90-day mortality in HBV-ACLF patients. An MAPT, inclusive of type and five other variables, was built and validated; it was found to be superior to the Chronic Liver Failure (CLIF) Consortium ACLF score, Model for End-Stage Liver Disease, CLIF-Sequential Organ Failure, and Child-Turcotte-Pugh scores in predicting 90-day mortality, with an area under the receiver operating characteristic curve of 0.802 (95% CI [0.763-0.836]), sensitivity of 71.77%, and specificity of 75.82%.

CONCLUSIONS

The MAPT model showed excellent predictive value for 90-day mortality in HBV-ACLF and can likely expand the clinical application of WGO ACLF classification.

A novel prognostic model to predict outcome of artificial liver support system treatment

The prognosis of Artificial liver support system (ALSS) for hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is hard to be expected, which results in multiple operations of ALSS and excessive consumption of plasma, increase in clinical cost. A total of 375 HBV-ACLF patients receiving ALSS treatment were randomly divided a train set and an independent test set. Logistic regression analysis was conducted and a decision tree was built based on 3-month survival as outcome. The ratio of total bilirubin before and after the first time of ALSS treatment was the most significant prognostic factor, we named it RPTB. Further, a decision tree based on the multivariate logistic regression model using CTP score and the RPTB was built, dividing patients into 3 main groups such as favorable prognosis group, moderate prognosis group and poor prognosis group. A clearly-presented and easily-understood decision tree was built with a good predictive value of prognosis in HBV-related ACLF patients after first-time ALSS treatment. It will help maximal the therapeutic value of ALSS treatment and may play an important role in organ allocation for liver transplantation in the future.

Tri-typing of hepatitis B-related acute-on-chronic liver failure defined by the World Gastroenterology Organization

BACKGROUND AND AIM

Tri-typing of acute-on-chronic liver failure (ACLF), as proposed by the World Gastroenterology Organization (WGO), has not been validated in patients infected with hepatitis B virus (HBV). We aim to compare the three types of ACLF patients in clinic characteristics.

METHODS

Hospitalized ACLF patients with chronic hepatitis B from five hepatology centers were retrospectively selected and grouped according to the WGO classification. For each group, we investigated laboratory tests, precipitating events, organ failure, and clinical outcome.

RESULTS

Compared with type-B (n = 262, compensated cirrhosis) and type-C (n = 129, decompensated cirrhosis) ACLF, type-A patients (n = 195, non-cirrhosis) were associated with a younger age, the highest platelet counts, the highest aminotransferase levels, and the most active HBV replications. HBV reactivation were more predominant in type-A, while bacterial infections in type-B and type-C ACLF cases. Liver failure (97.4%) and coagulation failure (86.7%) were most common in type-A compared with type-B or type-C ACLF patients. Kidney failure was predominantly identified in type-C subjects (41.9%) and was highest (23/38, 60.5%) in grade 1 ACLF patients. Furthermore, type-C ACLF showed the highest 28-day (65.2%) and 90-day (75.3%) mortalities, compared with type-A (48.7% and 54.4%, respectively) and type-B (48.4% and 62.8%, respectively) ACLF cases. Compared with type-A (11.7%) ACLF patients, the increased mortality from 28 to 90 days was higher in type-B (31.6%) and type-C (37.5%).

CONCLUSION

Tri-typing of HBV-related ACLF in accordance with the WGO definition was able to distinguish clinical characteristics, including precipitating events, organ failure, and short-term prognosis in ACLF patients.

Positive fluid balance was associated with mortality in patients with acute-on-chronic liver failure: A cohort study

PURPOSE

We aimed to study the effect of FB in the outcomes of critically-ill patients with cirrhosis.

MATERIALS

Retrospective analysis of all adult consecutive admissions of patients with cirrhosis and organ failures to the Intensive Care Unit (ICU) at Curry Cabral Hospital (Lisbon, Portugal) and University of Alberta Hospital (Edmonton, Canada) on 08/2013-08/2017. Primary exposure was FB at 3 and 7 days post ICU admission. Primary endpoint was hospital mortality.

RESULTS

Amongst 333 patients, median age was 56 years and 67.6% were men. Median MELD, APACHEII, CLIF-SOFA, and CLIF-C-ACLF scores on ICU admission were 27, 28, 14, and 54, respectively. ICU and hospital mortality rates were 33.0% and 49.2%, respectively. While median FB at 3 days post ICU admission (+5.46 l vs. +6.62 l; P = 0.74) was not associated with hospital mortality, higher median FB at 7 days post ICU admission (+13.50 l vs. +6.90 l; P = 0.036) was associated with higher hospital mortality. This association remained significant (OR 95%CI = 1.04 [1.01;1.07] per each l) after adjustment for confounders (age, ascites, infection, lactate, and number of organ failures).

CONCLUSIONS

FB may be a therapeutic target that helps to improve the outcomes of patients with acute-on-chronic liver failure. This data may inform future clinical trials.

Acute-on-chronic liver failure: to admit to intensive care or not?

Acute-on-chronic liver failure is used to describe an acute decline in liver function in a patient with existing liver disease combined with other organ failure. Acute-on-chronic liver failure is associated with high short-term mortality, and the greater the number and severity of organ failures, the higher the mortality. The most commonly identified precipitants of acute-on-chronic liver failure include bacterial infection, gastrointestinal haemorrhage, viral hepatitis and recent excessive alcohol intake. Since some of these aetiologies are treatable, organ failure may return to pre-decompensation levels in up to 55% of patients. As a result, a trial of critical care treatment may be appropriate for many of these patients. Clinical scoring tools may help clinicians recognise futility, allowing timely withdrawal of organ support and shifting the focus of care toward palliation.

High levels of serum interleukin-6 increase mortality of hepatitis B virus-associated acute-on-chronic liver failure

BACKGROUND

Patients with hepatitis B virus-associated acute-on-chronic liver failure (HBV-ACLF) present a complex and poor prognosis. Systemic inflammation plays an important role in its pathogenesis, and interleukin-6 (IL-6) as a pro-inflammatory cytokine is related with severe liver impairment and also plays a role in promoting liver regeneration. Whether serum IL-6 influences HBV-ACLF prognosis has not been studied.

AIM

To determine the impact of serum IL-6 on outcome of patients with HBV-ACLF.

METHODS

We performed a retrospective study of 412 HBV-ACLF patients. The findings were analyzed with regard to mortality and the serum IL-6 level at baseline, as well as dynamic changes of serum IL-6 within 4 wk.

RESULTS

The serum IL-6 level was associated with mortality. Within 4 wk, deceased patients had significantly higher levels of IL-6 at baseline than surviving patients [17.9 (7.3-57.6) vs 10.4 (4.7-22.3), P = 0.011]. Patients with high IL-6 levels (> 11.8 pg/mL) had a higher mortality within 4 wk than those with low IL-6 levels (≤ 11.8 pg/mL) (24.2% vs 13.2%, P = 0.004). The odds ratios calculated using univariate and multivariate logistic regression were 2.10 (95% confidence interval [CI]: 1.26-3.51, P = 0.005) and 2.11 (95%CI: 1.15-3.90, P = 0.017), respectively. The mortality between weeks 5 and 8 in patients with high IL-6 levels at 4 wk was 15.0%, which was significantly higher than the 6.6% mortality rate in patients with low IL-6 levels at 4 wk (hazard ratio = 2.39, 95%CI: 1.05-5.41, P = 0.037). The mortality was 5.0% in patients with high IL-6 levels at baseline and low IL-6 levels at 4 wk, 7.5% in patients with low IL-6 levels both at baseline and at 4 wk, 11.5% in patients with low IL-6 levels at baseline and high IL-6 levels at 4 wk, and 16.7% in patients with high IL-6 levels both at baseline and at 4 wk. The increasing trend of the mortality rate with the dynamic changes of IL-6 was significant (P for trend = 0.023).

CONCLUSION

A high level of serum IL-6 is an independent risk factor for mortality in patients with HBV-ACLF. Furthermore, a sustained high level or dynamic elevated level of serum IL-6 indicates a higher mortality.

Glucocorticoid versus traditional therapy for hepatitis B virus-related acute-on-chronic liver failure: A systematic review and meta-analysis

OBJECTIVE

This meta-analysis aimed to assess the efficacy and safety of glucocorticoid versus traditional therapy for hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF).

METHODS

PubMed, Cochrane Central Register of Clinical Trials, and EMBASE were searched. All clinical studies, including randomized controlled studies and cohort studies, comparing glucocorticoids with traditional treatments (until November 1, 2018), were included.

RESULTS

A total of 3 randomized controlled trials and 5 cohort studies (including 3 retrospective cohort studies), involving 538 patients, were subjected to the meta-analysis. The total bilirubin levels before treatment were not significantly different (odds ratio [OR]: -0.97; 95% confidence interval [CI]: -2.56 to 0.62; P = .23), and, however, they were significantly reduced after treatment in the corticosteroid group compared with the traditional treatment group (OR: -8.83; 95% CI: -14.99 to 2.67; P = .005). Moreover, prothrombin time was significantly long before treatment in either group, with no significant differences (OR: 0.28; 95% CI: -0.79 to 1.34; P = 0.61). However, after treatment, prothrombin time was significantly shortened in the traditional treatment group (OR: 31.71; 95% CI: 3.62-59.81; P = .03). Furthermore, inpatient mortality (OR: 0.23; 95% CI: 0.08-0.67; P = .007) and ascites events (OR: 0.35; 95% CI: 0.18-0.67; P = .90) were significantly lower in the corticosteroid treatment group.

CONCLUSIONS

Glucocorticoid is more effective for reducing the T-bili level, significantly decreasing in-hospital mortality and ascites events in HBV-related ACLF patients. Moreover, bilirubin may play a pivotal role in the early stage of HBV-related ACLF progression to advanced liver failure.

Acute-on-chronic liver failure syndrome - clinical results from an intensive care unit in a liver transplant center

OBJECTIVE

To characterize a cohort of acute-on-chronic liver failure patients in Intensive Care and to analyze the all-cause 28-day mortality risk factors assessed at ICU admission and day 3.

METHODS

This was a retrospective cohort study of consecutive patients admitted to the intensive care unit between March 2013 and December 2016.

RESULTS

Seventy-one patients were included. The median age was 59 (51 - 64) years, and 81.7% of patients were male. Alcohol consumption alone (53.5%) was the most frequent etiology of cirrhosis and infection (53.5%) was the most common acute-on-chronic liver failure precipitating event. At intensive care unit admission, the clinical severity scores were APACHE II 21 (16 - 23), CLIF-SOFA 13 (11 - 15), Child-Pugh 12 (10 - 13) and MELD 27 (20 - 32). The acute-on-chronic liver failure scores were no-acute-on-chronic liver failure: 11.3%; one: 14.1%; two: 28.2% and three: 46.5%; and the number of organ failures was one: 4.2%; two: 42.3%; three: 32.4%; four: 16.9%; and five: 4.2%. Liver transplantation was performed in 15.5% of patients. The twenty-eight-day mortality rate was 56.3%, and the in-ICU mortality rate was 49.3%. Organ failure at intensive care unit admission (p = 0.02; OR 2.1; 95%CI 1.2 - 3.9), lactate concentration on day 3 (p = 0.02; OR 6.3; 95%CI 1.4 - 28.6) and the international normalized ratio on day 3 (p = 0.03; OR 10.2; 95%CI 1.3 - 82.8) were independent risk factors.

CONCLUSION

Acute-on-chronic liver failure patients presented with high clinical severity and mortality rates. The number of organ failures at intensive care unit admission and the lactate and international normalized ratio on day 3 were independent risk factors for 28-day mortality. We consider intensive care essential for acute-on-chronic liver failure patients and timely liver transplant was vital for selected patients.

Cirrhotic Patients Admitted to the ICU With Septic Shock: Factors Predicting Short and Long-Term Outcome

Cirrhotic patients with septic shock have a poor prognosis in ICU compared to general population of critically ill patients. Little is known about long-term outcome in these patients. We performed a retrospective analysis of a prospective cohort of cirrhotic patients with septic shock. The aim of this study was to describe both short and long-term outcomes and to evaluate factors predicting mortality. Data from 149 patients were analyzed (mean age: 60 ± 11 years, sex ratio: 2.4). Mortality rate in the ICU was 54% and at 1 year it was 73%. Among factors associated with adverse outcome, independent factors predicting ICU mortality were early need for renal replacement therapy (odds ratios, OR 13.95, 95% confidence interval, CI 3.30; 59.03) and arterial lactate >5 mmol.L (OR 7.27, 95% CI 2.92; 18.10), and early use of mechanical ventilation (OR 3.05, 95% CI 1.08; 8.58). For 1-year mortality, independent prognostic factors were the need for renal replacement therapy during ICU stay (OR 9.60, 95% CI 2.90; 31.82), prothrombin time ≤40% (OR 3.47, 95% CI 1.43; 8.43), and Charlson score (OR 1.36 per point, 95% CI 1.11; 1.67). The results emphasize the poor prognosis of cirrhotic patients with septic shock admitted to the ICU. The need for organ supports appears to be a better predictor of short-term outcome than the underlying hepatic disease. Renal replacement therapy is associated with both short and long-term outcomes.

Predictive factors for 28-day mortality in acute-on-chronic liver failure patients admitted to the intensive care unit

BACKGROUND

Acute-on-chronic liver failure (ACLF) is an entity comprising an acute deterioration of liver function in cirrhotic patients, associated with organ failure(s) and high short-term mortality. We aimed to identify predictive factors for short-term mortality in patients admitted with ACLF that may benefit most from liver transplantation.

METHODS

Retrospective analysis of patients admitted in ACLF to a tertiary intensive care unit between 2013 and 2017 was performed. The EASL-CLIF acute-on-chronic liver failure in cirrhosis (CANONIC) criteria were used to define ACLF grade. Multivariable analysis using 28-day mortality as an end-point was performed, including severity-of-disease scores and clinical parameters.

RESULTS

Seventy-seven patients were admitted in ACLF over the study period. The commonest aetiology of liver disease was alcohol related 52/77(68%) and the commonest precipitant of ACLF was variceal haemorrhage 38/77(49%). Overall 28-day mortality was 42/77(55%) [ACLF-(grade)1:3/42(7%); ACLF-2:10/42(24%); and, ACLF-3:29/42(69%);p = 0.002]. On multivariable analysis MELD ≥ 26 [odds ratio(OR) = 11.559; 95% confidence interval(CI):2.820-47.382;p = 0.001], ACLF-3 (OR = 3.287; 95%CI:1.047-10.325;p = 0.042) at admission and requirement for renal replacement therapy (OR = 5.348; 95%CI:1.385-20.645;p = 0.015) were independently associated with 28-day mortality.

CONCLUSION

Patients admitted with ACLF to intensive care have a high mortality rate. Defined early thresholds at admission can identify patients at the highest risk that may benefit most from liver transplantation.

The immunological roles in acute-on-chronic liver failure: An update

BACKGROUND

Acute-on-chronic liver failure (ACLF) refers to the acute deterioration of liver function that occurs in patients with chronic liver disease. ACLF is characterized by acute decompensation, organ failure and high short-term mortality. Numerous studies have been conducted and remarkable progress has been made regarding the pathophysiology and pathogenesis of this disease in the last decade. The present review was to summarize the advances in this field.

DATA SOURCES

A comprehensive search in PubMed and EMBASE was conducted using the medical subject words "acute-on-chronic liver failure", "ACLF", "pathogenesis", "predictors", and "immunotherapy" combined with free text terms such as "systemic inflammation" and "immune paralysis". Relevant papers published before October 31, 2018, were included.

RESULTS

ACLF has two marked pathophysiological features, namely, excessive systemic inflammation and susceptibility to infection. The systemic inflammation is mainly manifested by a significant increase in the levels of plasma pro-inflammatory factors, leukocyte count and C-reactive protein. The underlying mechanisms are unclear and may be associated with decreased immune inhibitory cells, abnormal expression of cell surface molecules and intracellular regulatory pathways in immune cells and increased damage-associated molecular patterns in circulation. However, the main cause of susceptibility to infection is immune paralysis. Immunological paralysis is characterized by an attenuated activity of immune cells. The mechanisms are related to elevations of immune inhibitory cells and the concentration of plasma anti-inflammatory molecules. Some immune biological indicators, such as soluble CD163, are used to explore the pathogenesis and prognosis of the disease, and some immunotherapies, such as glucocorticoids and granulocyte colony-stimulating factor, are effective on ACLF.

CONCLUSIONS

Overwhelming systemic inflammation and susceptibility to infection are two key features of ACLF. A better understanding of the state of a patient's immune system will help to guide immunotherapy for ACLF.

Acute kidney injury spectrum in patients with chronic liver disease: Where do we stand?

Acute kidney injury (AKI) is a common complication of liver cirrhosis and is of the utmost clinical and prognostic relevance. Patients with cirrhosis, especially decompensated cirrhosis, are more prone to develop AKI than those without cirrhosis. The hepatorenal syndrome type of AKI (HRS–AKI), a spectrum of disorders in prerenal chronic liver disease, and acute tubular necrosis (ATN) are the two most common causes of AKI in patients with chronic liver disease and cirrhosis. Differentiating these conditions is essential due to the differences in treatment. Prerenal AKI, a more benign disorder, responds well to plasma volume expansion, while ATN requires more specific renal support and is associated with substantial mortality. HRS–AKI is a facet of these two conditions, which are characterized by a dysregulation of the immune response. Recently, there has been progress in better defining this clinical entity, and studies have begun to address optimal care. The present review synopsizes the current diagnostic criteria, pathophysiology, and treatment modalities of HRS–AKI and as well as AKI in other chronic liver diseases (non-HRS–AKI) so that early recognition of HRS–AKI and the appropriate management can be established.

Predictive value of the Chinese group on the study of severe hepatitis B-acute-on-chronic liver failure score in the short-term prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND

As a large, prospective, multicenter study-based prognostic score for hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF), the Chinese group on the study of severe hepatitis B-acute-on-chronic liver failure score (COSSH-ACLFs), has been approved by some foreign scholars; however, its predictive value needs to be verified. This study investigated the predictive value of COSSH-ACLFs for short-term prognosis in Chinese patients with HBV-ACLF.

METHODS

This retrospective cohort study included 751 patients with HBV-ACLF admitted to the Fifth Medical Center of Chinese PLA General Hospital between January 2011 and December 2014. Spearman method was used to assess the correlation of COSSH-ACLFs with classical scores. Different COX multivariate regression models were used to confirm the relationship between COSSH-ACLFs and short-term prognosis in patients with HBV-ACLF, and stratified analysis was used to further verify the stability of this relationship. We compared the predictive powers of COSSH-ACLFs and other classical scores using area under the receiver operating characteristic curve (AUROC) and Z-test.

RESULTS

A total of 975 patients with HBV-ACLF were screened, and 751 were analyzed (623 male and 128 female). COSSH-ACLFs was the highest in patients with end-stage ACLF, followed by those with middle- and early-stage ACLF (H = 211.8, P < 0.001). In the fully adjusted model, COX multivariate regression analysis revealed that COSSH-ACLFs (as a continuous variable) was independently and positively correlated with mortality risk in patients with HBV-ACLF at 28 days (hazard ratio [HR]: 1.37 [1.22, 1.53], P < 0.001) and 90 days (HR: 1.43 [1.29, 1.58], P < 0.001). The same trend could be observed in the crude model and minimally adjusted model. The AUROCs of COSSH-ACLFs for 28-day and 90-day prognoses in patients with HBV-ACLF were 0.807 and 0.792, respectively, indicating a stronger predictive accuracy than those of classic models.

CONCLUSIONS

COSSH-ACLFs, with a superior predictive accuracy compared with other classical scores, can strongly predict short-term prognosis in Chinese patients with HBV-ACLF.

Lactate and number of organ failures predict intensive care unit mortality in patients with acute-on-chronic liver failure

BACKGROUND AND AIMS

Patients with acute-on-chronic liver failure (ACLF) have high mortality rates. Most prognostic scores were not developed for the intensive care unit (ICU) setting. We aimed to improve risk stratification for patients with ACLF in the ICU.

METHODS

A training set with 240 patients with cirrhosis and organ failures (Chronic Liver Failure Sequential Organ Failure Assessment score [CLIF-SOFA]) from Curry Cabral Hospital (Portugal) and University of Alberta Hospital (Canada) in 2010-2016 was used to derive a prognostic model for ICU mortality. A validation set with 237 patients with cirrhosis and organ failures from Vancouver General Hospital (Canada) in 2000-2011 was used to evaluate its performance.

RESULTS

Amongst patients in the training set, ICU and hospital mortality rates were 39.2% and 54.6% respectively. Median lactate (4.4 vs 2.5 mmol/L) and number of organ failures (3 vs 2) on admission to ICU were associated with higher likelihood of ICU mortality (P < 0.001 for both). The lactate and organ failures predictive model (LacOF) was derived to predict ICU mortality: -2.420 + 0.072 × lactate + 0.569 × number of organ failures (area under-the-curve [AUC], 0.76). In the validation set, the LacOF model discriminative ability (AUC, 0.85) outperformed the CLIF-SOFA (AUC, 0.79), Chronic Liver Failure Consortium Acute-on-Chronic Liver Failure (AUC, 0.73), Model for End-stage Liver Disease score (AUC, 0.78) and Acute Physiology and Chronic Health Evaluation II scores (AUC, 0.74; P < 0.05 for all). The LacOF model calibration was good up to the 25% likelihood of ICU mortality.

CONCLUSIONS

In patients with ACLF, lactate and number of organ failures on admission to ICU are useful to predict ICU mortality. This early prognostic evaluation may help to better stratify the risk of ICU mortality and thus optimize organ support strategies.

Nomogram prediction of individual prognosis of patients with acute-on-chronic hepatitis B liver failure

BACKGROUND

The current definitions and etiologies of acute-on-chronic liver failure (ACLF) are clearly very different between East and West.

AIMS

This study aimed to develop an effective prognostic nomogram for acute-on-chronic hepatitis B liver failure (ACHBLF) as defined by the Asia Pacific Association for the Study of the Liver (APASL).

METHODS

The nomogram was based on a retrospective study of 573 patients with ACHBLF, defined according to the APASL, at the Beijing Ditan Hospital. The results were validated using a bootstrapped approach to correct for bias in two external cohorts, including an APASL ACHBLF cohort (10 hospitals, N = 329) and an EASL-CLIF ACHBLF cohort (Renji Hospital, N = 300).

RESULTS

Multivariate analysis of the derivation cohort for survival analysis helped identify the independent factors as age, total bilirubin, albumin, international normalized ratio, and hepatic encephalopathy, which were included in the nomogram. The predictive value of nomogram was the strongest compared with CLIF-C ACLF, MELD and MELD-Na and similar to COSSH-ACLF in both the derivation and prospective validation cohorts with APASL ACHBLF, but the CLIF-C ACLF was better in the EASL-CLIF ACHBLF cohort.

CONCLUSIONS

The proposed nomogram could accurately estimate individualized risk for the short-term mortality of patients with ACHBLF as defined by APASL.

Acute-on-chronic liver failure in children with biliary atresia awaiting liver transplantation

OBJECTIVES

Acute-on-chronic liver failure (ACLF) is an acute decompensation of cirrhosis complicated by other organ failure and is associated with increased mortality and morbidity. ACLF has not been studied in children with biliary atresia (BA), which is the commonest indication for pediatric liver transplantation (LT) worldwide. This study aims to evaluate ACLF and outcomes in children with BA while awaiting deceased donor LT.

METHODS

This was a subanalysis of the dataset from a prospective cohort study of patients aged 0-18 years who underwent portoenterostomy for BA and were listed for LT at King's College Hospital, London, between 1999 and 2003. Outcomes included the development of ACLF, mortality, and complications.

RESULTS

Ninety-nine (41 male) children were included, and follow-up was 10 [6.0-15.0] years. A total of 20/99 children developed ACLF. ACLF was associated with increased mortality while awaiting LT (20% vs 4%; P = 0.03). There were no associations between biochemical parameters at listing and death. Increased bilirubin levels 3 months post-portoenterostomy was predictive of development of ACLF (AUROC = 0.72, P < 0.01). Age at LT and time on the waiting list in the ACLF subgroup were both lower compared to the non-ACLF group (P > 0.05). Sepsis and gastrointestinal bleeding were the commonest precipitants of ACLF. Complications included ascites, hepatic encephalopathy, and hepatorenal syndrome; the ACLF subgroup required multisystem support and longer intensive care unit stay.

CONCLUSIONS

ACLF in children with BA awaiting deceased donor LT carries increased mortality and morbidity. This warrants stratification of patients for earlier wait-listing and prioritization for LT.

Circulating proteomic panels for diagnosis and risk stratification of acute-on-chronic liver failure in patients with viral hepatitis B

Chronic HBV infection (CHB) can lead to acute-on-chronic liver failure (HBV-ACLF) characterized by high mortality. This study aimed to reveal ACLF-related proteomic alterations, from which protein based diagnostic and prognostic scores for HBV-ACLF were developed. Methods: Ten healthy controls, 16 CHB, and 19 HBV-ACLF according to COSSH (Chinese group on the study of severe hepatitis B) criteria were enrolled to obtain the comprehensive proteomic portrait related to HBV-ACLF initiation and progression. Potential markers of HBV-ACLF were further selected based on organ specificity and functionality. An additional cohort included 77 healthy controls, 92 CHB and 71 HBV-ACLF was used to validate the proteomic signatures via targeted proteomic assays. Results: Significant losses of plasma proteins related to multiple functional clusters, including fatty acid metabolism/transport, immuno-response, complement and coagulation systems, were observed in ACLF patients. In the validation study, 28 proteins were confirmed able to separate ACLF, CHB patients. A diagnostic classifier P4 (APOC3, HRG, TF, KLKB1) was built to differentiate ACLF from CHB with high accuracy (auROC = 0.956). A prognostic model P8 (GC, HRG, HPR, SERPINA6, age, NEU, INR and total protein) was built to distinguish survivors from non-survivors in 28 and 90-days follow-up (auROC = 0.882, 0.871), and to stratify ACLF patients into risk subgroups showing significant difference in 28 and 90-days mortality (HR=7.77, 7.45, both P<0.0001). In addition, P8 score correlated with ACLF grades and numbers of extra-hepatic organ failures in ACLF patients, and was able to predict ACLF-associated coagulation and brain failure within 90 days (auROC = 0.815, 0.842). Conclusions: Proteomic signatures developed in this study reflected the deficiency of key hematological functions in HBV-ACLF patients, and show potential for HBV-ACLF diagnosis and risk prediction in complementary to current clinical based parameters.

Next generation sequencing reveals novel alterations in B-cell heavy chain receptor repertoires associated with acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a newly-defined serious syndrome with major features of acute decompensation (AD) of hepatic cirrhosis, liver failure and failure of multiple other organs. To date, the mechanism underlying the development and progression of ACLF remains to be fully elucidated. It has been noted that ACLF is associated with immune dysregulation. However, studies have mainly focused on T-cell responses. The present study aimed to determine the composition and alterations of B-cell receptor (BCR) heavy chain repertoires associated with ACLF using next generation sequencing (NGS). A total of six patients with hepatitis B virus (HBV)-related ACLF and six healthy control subjects were prospectively enrolled in the present study. The B-cell immunoglobulin heavy chain (IGH) repertoires in peripheral blood mononuclear cells (PBMCs) obtained from the patients with HBV-related ACLF and the control subjects were analyzed using NGS, coupled with multiplex polymerase chain reaction, were Illumina sequenced, and were further characterized using the international ImMunoGeneTics database. The distribution of the BCR complementarity-determining region 3 (CDR3) variable (V), diversity (D) and joining (J) and V-J gene segments were found to be comparable between the ACLF and control groups. Of note, the degree of clonal expansion in the ACLF group was significantly higher than that in the control group (P<0.05). Furthermore, a t-test of the distribution ratio of the V, D, J and V-J combinations in patients with ACLF and control subjects revealed differentially expressed genes. In total, six genes were upregulated and 19 genes were downregulated in response to ACLF. The difference between these two groups was statistically significant (P<0.05). The approach used in the present study was feasible and effective for analyzing peripheral B-cell repertoires in HBV-related ACLF. These results provide direct evidence that the BCR repertoire is important in immune responses, autoimmunity and alloreactivity, and that there is a link between the BCR repertoire and HBV-ACLF. Therefore, ACLF-specific BCR CDR3 sequences hold promise for therapeutic benefit to HBV-ACLF in the future.

Human mesenchymal stem cells for hepatitis B virus-related acute-on-chronic liver failure: a systematic review with meta-analysis

BACKGROUND AND AIM

Acute-on-chronic liver failure (ACLF) is a condition with high mortality. New strategies are urgently required. The present review aims to provide a comprehensive understanding of the efficacy and safety of mesenchymal stem cells (MSC) treatment in patients with ACLF associated with hepatitis B virus infection.

MATERIALS AND METHODS

The MEDLINE, Embase, and Cochrane Library databases were searched for the relevant publications. If appropriate, a meta-analysis was carried out for the following outcomes: survival rate, model for end-stage liver disease score, and liver function.

RESULTS

Three studies were eligible for the present systematic review. A total of 198 hepatitis B virus-ACLF patients were enrolled for this review. Ninety-one patients were treated with MSC and 107 patients were treated with standard medical therapy (SMT) as controls. Pooled results showed that MSC treatment could significantly reduce the mortality rate at week 12 [risk ratio: 0.50; 95% confidence interval (CI): 0.33, 0.76; P=0.00009] and the mortality rate at the final follow-up (risk ratio: 0.54; 95%CI: 0.37, 0.78; P=0.001) compared with the SMT group. Furthermore, pooled estimates showed that MSC treatment could significantly reduce the total bilirubin level at week 4 (mean difference: 58.89; 95%CI: 14.47, 103.32; P=0.009) compared with the SMT group. No severe complication associated with MSC treatment was observed.

CONCLUSION

Our pooled results suggested that MSC treatment could significantly reduce the mortality rate, without increasing the incidence of severe complications.

Serum sodium, model for end-stage liver disease, and a recent invasive procedure are risk factors for severe acute-on-chronic liver failure and death in cirrhotic patients hospitalized with bacterial infection

INTRODUCTION

Bacterial infection is present in up to 30% of hospitalized cirrhotic patients. It can lead, even after its resolution, to organ dysfunction and even acute-on-chronic liver failure (ACLF). It is the precipitating factor of ACLF in one third of the cases and is the main cause of mortality in patients with liver cirrhosis.

OBJECTIVES

The aim of this study was to evaluate the prevalence and identify early risk factors for severe ACLF and death in hospitalized patients with liver cirrhosis with bacterial infection.

PATIENTS AND METHODS

This was a prospective observational study. Hospitalized patients with liver cirrhosis and bacterial infection were included. Clinical and laboratory data and their evolution to organ dysfunction and death were assessed. A statistical analysis were carried out to identify predictors of severe ACLF and in-hospital mortality.

RESULTS

This study included 88 patients. ACLF was observed in 62 (70%) patients, with 48 (55%) grade 2 or higher. Of the 27 deaths (31% of all patients), 26 had severe ACLF (54% mortality) (P<0.0001). The independent risk factors for ACLF of at least 2 and death were baseline serum sodium [odds ratio (OR): 0.874; P=0.01, and OR: 0.9, P=0.04], initial MELD (OR: 1.255, P=0.0001, and OR: 1.162, P=0.005), and a recent invasive procedure (OR: 3.169, P=0.01, and OR: 6.648, P=0.003).

CONCLUSION

Lower serum sodium values, higher MELD scores at diagnosis of infection, and a recent history of invasive procedures were independent risk factors for severe ACLF and death in patients with cirrhosis and bacterial infection.

Prediction model of the progression of patients with acute deterioration of hepatitis B virus-related chronic liver disease to acute-on-chronic liver failure

This study aimed to establish a new model for predicting acute-on-chronic liver failure (ACLF) (defined by the Chinese Medical Association), which potentially occurs among patients with acute deterioration (AD) of hepatitis B virus (HBV)-related chronic liver disease (CLD).A total of 754 patients with AD of HBV-related CLD (total bilirubin (TBIL) > 51.3 μmol/L and prothrombin activity (PTA) < 60%, 40% < PTA < 60% when TBIL ≥ 171.1 μmol/L) were retrospectively analyzed and divided into a training cohort (580 patients) and a validation cohort (174 patients). The ACLF occurrence probability of these patients was statistically analyzed within 4 weeks. In the training cohort, multivariate logistic regression analysis was performed to determine the independent predictors of ACLF occurrence and to develop a new prediction model. The validation cohort was utilized to verify and evaluate the value of the new prediction model.Within 4 weeks, 9.9% of the patients progressed to ACLF (12.0 ± 6.7 days). The new prediction model was characterized by R = 3.090 + 0.035 × Age (years) - 0.050 × PTA (%) + 0.005 × TBIL (μmol/L) + 0.044 × D/T (%) - 0.072 × Na (mmol/L) + 0.180 × HBV DNA (log10IU/mL). The areas under the receiver operating characteristic curves of the training and validation cohorts in the new model were higher than those in the model for end-stage liver disease.The new prediction model could be used by clinicians to recognize patients with AD of HBV-related CLD with high risks of progressing to ACLF.

Monocyte human leukocyte antigen - Antigen D related, neutrophil oxidative burst and cytokine analysis in patients of decompensated cirrhosis with and without acute-on chronic liver failure

Background and aim

Due to a dysregulated immune response, patients with acute-on-chronic liver failure (ACLF) have increased risk of infection and multi organ failure in comparison to compensated cirrhosis. The comparative data on the presence of ‘immune paresis’ in patients with ACLF and decompensated cirrhosis without ACLF is not available. Aim of the present study was to compare the immunological parameters in patients with decompensated cirrhosis with and without ACLF.

Methodology

In a prospective study, 76 patients with decompensated cirrhosis with (n = 38) and without (n = 38) ACLF and 10 healthy controls (HC) were evaluated for monocytic human leukocyte antigen–antigen D Related (HLA-DR) expression, mean density of HLA-DR expressed on the surface of these cells, neutrophil oxidative burst (NOB) capacity and serum levels of cytokines (IL-1, IL-6, IL-8, IL10, IL-12, and TNF-α).

Results

Patients of decompensated cirrhosis with and without ACLF demonstrated significantly lower mean percentage of monocytes expressing HLA-DR and quantitative increase in the NOB after stimulation with PMA when compared to HC. However there was no difference in mean percentage of monocytes with HLA-DR expression (43.61±26.56% vs. 43.10±20.98%) (p = 0.91), mean density of HLA-DR expression on the surface (30.34±29.32 vs. 41.71±52.13) (p = 0.42) and quantitative increase in NOB after stimulation with PMA (16.55±11.91 vs. 17.24±16.18) (p = 0.47) amongst patients with decompensated cirrhosis with and without ACLF. Patients with ACLF had significantly higher pro-inflammatory and anti-inflammatory cytokines in comparison to patients with decompensated cirrhosis without ACLF.

Conclusion

Patients with decompensated cirrhosis demonstrate a component of immune-paresis, however there is similar impairment in HLA–DR expression and NOB capacity in patients with and without ACLF. Both inflammatory and anti-inflammatory cytokines are increased in patients with ACLF in comparison to patients with decompensated cirrhosis without ACLF.

Acute on Chronic Liver Failure-In-Hospital Predictors of Mortality in ICU

AIMS

We studied in-hospital predictors of mortality of acute on chronic liver failure (ACLF) in Indian patients.

METHODS

Patients admitted to the intensive care unit of our institute fulfilling the definition of ACLF based on the Asia-Pacific Association for Study of Liver Disease (APASL) consensus were included. Complete history and medical evaluation to assess the etiology of underlying liver cirrhosis and to identify the acute precipitating insult of worsening liver function was done. Data was prospectively recorded and various scoring systems and individual clinical and laboratory parameters were assessed to identify predictors of 28 days mortality.

RESULTS

64 out of 240 patients screened for ACLF were analyszed in the study. Median age was 44 years and 53% were males. Alcohol was the primary cause of cirrhosis in 60.93%. Infections and active alcoholism was the main precipitating acute insult in 43% and 37% patients respectively. 28% patients had history of ingestion of hepato-toxic drugs as the acute insult. More than one acute insult was seen in 37.5% patients and type-II hepatic injury was the most common type. 28 days in hospital mortality was 43.75% and was highest in patients with sepsis (67.8%). Presence of hepato-renal syndrome and need for ventilation was associated with poor outcome. Though multiple variables were significant in predicting mortality on univariate analysis, yet on regression model only APACHE II and shock could significantly predict mortality with odds ratio of 3.18 and 9.14 respectively. Highest mortality was seen with cerebral and lung as organ failure and mortality increased as the number of organ failure worsened. CLIF-SOFA and APACHE-II scores having area under curve > 0.8 had higher ability to predict mortality.

CONCLUSION

ACLF carries high short-term mortality and early intervention by liver transplantation should be considered in patients who shows high risk of mortality.

Potentially inappropriate liver transplantation in the era of the "sickest first" policy - A search for the upper limits

Liver transplantation has emerged as a highly efficient treatment for a variety of acute and chronic liver diseases. However, organ shortage is becoming an increasing problem globally, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of losing the graft during transplantation or in the initial postoperative period after liver transplantation (three months). This trend is challenging the model for end-stage liver disease allocation system, where the sickest candidates are prioritised and no delisting criteria are given. The weighting of the deontological demand for "equity", trying to save every patient, regardless of the overall utility; and "efficiency", rooted in utilitarianism, trying to save as many patients as possible and increase the overall quality of life of patients facing the same problem, has to be reconsidered. In this article we are aiming to overcome the widespread concept of futility in liver transplantation, providing a definition of potentially inappropriate liver transplantation and giving guidance on situations where it is best not to proceed with liver transplantation, to decrease the mortality rate in the first three months after transplantation. We propose "absolute" and "relative" conditions, where early post-transplant mortality is highly probable, which are not usually captured in risk scores predicting post-transplant survival. Withholding liver transplantation for listed patients in cases where liver transplant is not deemed clearly futile, but is potentially inappropriate, is a far-reaching decision. Until now, this decision had to be discussed extensively on an individual basis, applying explicit communication and conflict resolution processes, since the model for end-stage liver disease score and most international allocation systems do not include explicit delisting criteria to support a fair delisting process. More work is needed to better identify cases where transplantation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, following a societal debate on what we owe to all liver transplant candidates.

Cirrhotic patients admitted to the ICU for medical reasons: Analysis of 5506 patients admitted to 286 ICUs in 8years

PURPOSE

To describe characteristics and prognostic factors of cirrhotic patients admitted to a representative sample of Italian intensive care units (ICUs).

MATERIALS AND METHODS

All patients admitted to 286 ICUs for medical reasons between 2002 and 2010 (excluding 2007) were considered. A logistic regression model was developed on cirrhotics to predict hospital mortality. The prediction was applied to different subgroups defined by both the level of unit expertise with cirrhotics and the overall unit performance, and compared to the actual mortality.

RESULTS

5506 cirrhotic patients (32.1% admitted to the ICU for non-cirrhotic-related reasons) were compared to 130,477 controls. Hospital mortality was higher in cirrhotics (57.2% vs. 35.0%, p<0.001). ICU volume of cirrhotic patients did not influence mortality, while the overall performance of the unit did. The standardized mortality ratio for overall lower-performing units was 1.09 (95%CI: 1.05-1.14), for the average-performing units it was 1.01 (95%CI: 0.98-1.04), for the higher-performing units it was 0.92 (95%CI: 0.89-0.96).

CONCLUSIONS

The outcome of critically ill cirrhotic patients is quite poor, but not to limit their admission to the ICU. When cirrhosis accompanies other acute conditions, the general level of intensive care medicine is more important than the specific liver-oriented expertise in treating these patients.

Stratified alpha-fetoprotein pattern accurately predicts mortality in patients with acute-on-chronic hepatitis B liver failure

BACKGROUND

Alpha-fetoprotein (AFP) has been shown to predict the prognosis of liver disease in several studies. This study aimed to evaluate the prognostic value of stratified AFP in patients with acute-on-chronic hepatitis B liver failure (ACHBLF).

METHODS

A total of 192 patients were included and AFP were categorized into quartiles. The prognostic value was determined for overall survival (OS) and assessed by Kaplan-Meier analysis. Univariate and multivariate Cox proportional hazard regression analyses studied the association of all independent parameters with disease prognosis.

RESULTS

The optimal cut-off points of AFP were: (Q1) 252.3-4800.0 ng/ml, (Q2) 76.0-252.2 ng/ml, (Q3) 18.6-75.9 ng/ml, and (Q4) 0.7-18.5 ng/ml. Based on the Kaplan-Meier analysis of the OS, each AFP quartile revealed a progressively worse OS and apparent separation (log-rank P = 0.006). The second-highest quartiles of AFP (Q2) always demonstrated an extremely favorable short-term survival. Combining the lowest AFP quartiles with a serum sodium < 131mmol/L or an INR ≥ 3.3 showed a poor outcome (90-days survival of 25.0% and 11.9% respectively).

CONCLUSIONS

Stratified AFP could strengthen the predictive power for short-term survival of patients with ACHBLF. Combining AFP quartiles with low serum sodium and high INR may better predict poor outcome in ACHBLF patients.

Comparison of five different scoring models for predicting short-term mortality in patients with alcohol-related acute-on-chronic liver failure

AIM

To compare the performance of age, bilirubin, INR, and creatinine (ABIC), Maddrey's discriminant function (MDF), model for end-stage liver disease (MELD), chronic liver failure-sequential organ failure assessment (CLIF-SOFA), and Child-Turcotte-Pugh (CTP) in predicting short-term mortality in patients with alcohol-related acute-on-chronic liver failure (ACLF).

METHODS

There were 462 consecutive patients with live failure treated from August 2005 to June 2017 at Tianjin Third Central Hospital, of whom 152 with alcohol-related ACLF were finally enrolled in this study according to the inclusion criteria and exclusion criteria. We divided patients into either group A or group B. Patients in group A met the criteria of Asian Pacific Association for the Study of the Liver but did not met the criteria of European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF), and patients in group B met the criteria of EASL-CLIF on admission. The performance of different scoring models in predicting short-term mortality was assessed using the area under the receiver operating characteristic curve (AUC-ROC).

RESULTS

The 28-d mortality rate was 19% in group A and 50% in group B (P = 0.002). In group A, the AUC of CLIF-SOFA for predicting the 28-d mortality was highest (0.889), followed by MELD (0.761), MDF (0.738), ABIC (0.718), and CTP (0.671), and there was a significant difference between CTP and the others. In group B, the AUC of CLIF-SOFA was 0.916, followed by MELD (0.804), MDF (0.770), ABIC (0.729), and CTP (0.647), and there was a significant difference between CLIF-SOFA and the others and between CTP and the others.

CONCLUSION

The five scoring systems could all predict the short-term prognosis of the two groups of patients. However, CLIF-SOFA performs well compared to the others, regardless of patients in group A or group B.

Influence of proton pump inhibitors in the development of spontaneous bacterial peritonitis

AIM

To investigate whether the use of proton pump inhibitors (PPIs) increases the incidence of spontaneous bacterial peritonitis (SBP) in patients with cirrhosis and ascites.

METHODS

An historical cohort study was carried out in cirrhotic outpatients with ascites followed in a specialized clinic at a tertiary hospital in Southern Brazil. Patient charts were reviewed to collect information on the variables of interest as the use of PPIs. Primary outcome was defined as development of SBP during the study period. SBP was diagnosed based on ascitic fluid polymorphonuclear cell count ≥ 250 cells/mm³ without evidence of an intra-abdominal, surgically treatable source of infection.

RESULTS

Of 738 cirrhotic patients, 582 (58.2% male) were enrolled, with mean age of 53.6 ± 12 years. Hepatitis C virus infection (36.2%) and alcohol abuse (25.6%) were the main etiologies of cirrhosis. The presence of ascites was detected in 299 (51.4%) patients during the development of the study. Nineteen patients with previous diagnosis of SBP undergoing secondary prophylaxis and 22 patients with insufficient PPI data were further excluded. Of 258 patients with ascites, 151 used PPIs, and 34 developed SBP (22.5%). Among 107 non-users of PPIs, 23 developed SBP (21.5%) (HR = 1.44, 95%CI: 0.85-2.47, P = 0.176). The median follow-up time of patients using PPI was 27 mo vs 32 mo for non-users. Univariate analysis of the risk factors associated with the development of SBP revealed a significant association of SPB with the severity of liver disease according to the Child-Turcotte-Pugh (CTP) score. Multivariate analysis confirmed that CTP score was the only independent variable influencing the occurrence of SBP. Survival at 60 mo (Kaplan-Meier analysis) was similar in users and non-users of PPI, independently of the presence of SBP (58.4% vs 62.7% respectively, P = 0.66). For patients with SBP, survival at 60 mo was 55.1%, vs 61.7% in patients without SBP (P = 0.34).

CONCLUSION

In conclusion, the rate of SBP was not significantly different in users or non-users of PPIs in this cohort of cirrhotic with ascites.