急性慢性肝衰竭是一种独特的综合征在急性失代偿性肝硬化

StephenW

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.

StephenW

急性失代偿（AD）和器官衰竭住院的肝硬化患者即将死亡的风险，并认为有急性慢性肝衰竭（ACLF）。然而，有没有制定的诊断标准为ACLF，所以很少有人知道它的发展和进步。我们的目的，ACLF确定的诊断标准和描述这种综合征在欧洲与AD患者的发展。
方法：

我们收集到的数据，从1343例住院肝硬化患者在8个欧洲国家的29例肝单位和公元2011年2月至9。我们使用的器官功能衰竭和死亡率数据ACLF牌号定义，评估死亡率，并确定ACLF和AD之间的差异。我们制定的诊断标准为ACLF的基础上分析器官功能衰竭患者（定义为慢性肝功能衰竭序贯器官衰竭评估[CLIF沙发]评分）和28天死亡率高（> 15％）。
结果：

评估的患者中，有303 ACLF在研究开始时，112开发ACLF，和928没有ACLF。 ACLF在研究开始时28天患者死亡率为33.9％，其中ACLF为29.7％，谁开发，谁没有ACLF为1.9％之间。 ACLF患者更年轻，更经常酒精，有多个相关的细菌感染，并有较高的白细胞和C-反应蛋白的血浆水平较高的患者比无ACLF组（P <0.001）。 CLIF SOFA评分和白细胞计数与ACLF患者死亡率的独立预测因素。无病史的AD患者，ACLF意外特点ACLF在病史的AD患者相比器官衰竭，白细胞计数和死亡率较高的数字。
结论：

我们分析肝硬化和AD患者建立诊断标准ACLF的数据表明，它是有别于AD，不仅基于器官功能衰竭（s）和高死亡率也年龄，促发事件，和全身的存在炎症。 ACLF死亡率与器官功能和高的白细胞计数的损失。 ACLF尤其是严重在没有病史AD患者

StephenW

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.

急性慢性肝功能衰竭是一个独立的实体
与Atif扎曼，MD，MPH审查莫罗R等。胃肠病学2013六月

新的诊断标准是可用来帮助医生更好地识别这种高风险的肝硬化患者的子集。

急性失代偿，定义为腹水，细菌感染，肝性脑病，或胃肠道出血的发展，可发生于晚期肝病的初期表现为幕与已知的肝硬化患者。急性失代偿患者的器官功能衰竭的进展通常被称为急性慢性肝衰竭（ACLF），一直伴随着非常差的短期生存。然而，ACLF的标准定义是缺乏。

为了更好地确定ACLF，研究人员前瞻性地评估了1343名患者住院治疗的29例肝诊所在8个欧洲国家的危险因素和临床结果。器官功能衰竭和死亡率数据被用来定义ACLF等级和确定ACLF之间的差异和急性失代偿。

ACLF在研究招生303名患者被确诊。 28天的随访期间，有112名患者ACLF，和928没有。 28天的死亡率显着更高的在ACLF患者在研究开始时（33.9％），和ACLF谁开发谁没有ACLF（1.9％的患者在研究过程中（29.7％）相比，） 。 ACLF的风险因素包括年龄较轻，主动酗酒，相关的细菌感染，白细胞计数较高，C-反应蛋白水平升高。
评论

在这种大型，前瞻性研究调查发现，作为一个独立的实体，与前者相关的15倍，更高的28天死亡率急性失代偿性肝硬化疾病肝硬化患者的急性发作，慢性肝功能衰竭。 ACLF似乎与全身炎症或感染，主动使用酒精。 ACLF区分急性失代偿独自在临床的设置，可能让医生给患者更好的预后信息。