Gastroenterology. 2013 Jun;144(7):1426-37, 1437.e1-9. doi: 10.1053/j.gastro.2013.02.042. Epub 2013 Mar 6.
Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis.
Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, Durand F, Gustot T, Saliba F, Domenicali M, Gerbes A, Wendon J, Alessandria C, Laleman W, Zeuzem S, Trebicka J, Bernardi M, Arroyo V; CANONIC Study Investigators of the EASL–CLIF Consortium.
Collaborators (81)
Source
Service d'Hépatologie, Hôpital Beaujon, Assistance Publique-Hôpitaux de Paris, Clichy, France.
Abstract
BACKGROUND & AIMS:
Patients with cirrhosis hospitalized for an acute decompensation (AD) and organ failure are at risk for imminent death and considered to have acute-on-chronic liver failure (ACLF). However, there are no established diagnostic criteria for ACLF, so little is known about its development and progression. We aimed to identify diagnostic criteria of ACLF and describe the development of this syndrome in European patients with AD.
METHODS:
We collected data from 1343 hospitalized patients with cirrhosis and AD from February to September 2011 at 29 liver units in 8 European countries. We used the organ failure and mortality data to define ACLF grades, assess mortality, and identify differences between ACLF and AD. We established diagnostic criteria for ACLF based on analyses of patients with organ failure (defined by the chronic liver failure-sequential organ failure assessment [CLIF-SOFA] score) and high 28-day mortality rate (>15%).
RESULTS:
Of the patients assessed, 303 had ACLF when the study began, 112 developed ACLF, and 928 did not have ACLF. The 28-day mortality rate among patients who had ACLF when the study began was 33.9%, among those who developed ACLF was 29.7%, and among those who did not have ACLF was 1.9%. Patients with ACLF were younger and more frequently alcoholic, had more associated bacterial infections, and had higher numbers of leukocytes and higher plasma levels of C-reactive protein than patients without ACLF (P < .001). Higher CLIF-SOFA scores and leukocyte counts were independent predictors of mortality in patients with ACLF. In patients without a prior history of AD, ACLF was unexpectedly characterized by higher numbers of organ failures, leukocyte count, and mortality compared with ACLF in patients with a prior history of AD.
CONCLUSIONS:
We analyzed data from patients with cirrhosis and AD to establish diagnostic criteria for ACLF and showed that it is distinct from AD, based not only on the presence of organ failure(s) and high mortality rate but also on age, precipitating events, and systemic inflammation. ACLF mortality is associated with loss of organ function and high leukocyte counts. ACLF is especially severe in patients with no prior history of AD. 作者: StephenW 时间: 2013-7-26 20:38
Acute-on-Chronic Liver Failure Is a Distinct Entity
Atif Zaman, MD, MPH reviewing Moreau R et al. Gastroenterology 2013 Jun.
New diagnostic criteria are available to help clinicians better identify this high-risk subset of patients with cirrhosis.
Acute decompensation, defined as development of ascites, bacterial infection, encephalopathy, or gastrointestinal bleeding, can occur at initial presentation of advanced liver disease or episodically in patients with known cirrhosis. Progression to organ failure in patients with acute decompensation is typically termed acute-on-chronic liver failure (ACLF), which has been associated with very poor short-term survival. However, a standard definition of ACLF is lacking.
To better define ACLF, researchers prospectively evaluated risk factors and clinical outcomes of 1343 patients hospitalized in 1 of 29 liver clinics in eight European countries. Organ failure and mortality data were used to define ACLF grades and identify differences between ACLF and acute decompensation.
ACLF was diagnosed in 303 patients at study enrollment. During 28 days of follow-up, 112 patients developed ACLF, and 928 did not. The 28-day mortality rate was significantly higher both in patients who had ACLF at the time the study began (33.9%) and in those who developed ACLF during the study (29.7%) compared with patients who did not have ACLF (1.9%). Risk factors for ACLF included younger age, active alcoholism, associated bacterial infections, higher leukocyte count, and elevated C-reactive protein levels.
Comment
In this large, prospective study, investigators identified acute-on-chronic liver failure in patients with cirrhosis as a distinct disease entity from cirrhosis with acute decompensation only, with the former associated with a 15-fold higher 28-day mortality rate. ACLF seems to be related to systemic inflammation or infection and active alcohol use. Differentiating between ACLF and acute decompensation alone in a clinical setting may allow clinicians to give better prognostic information to patients.