State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China.
Department of Hepatology, Ningbo No. 2 Hospital, Ningbo, China.
Hepatology. 2015 Jul;62(1):232-42. doi: 10.1002/hep.27795. Epub 2015 Apr 25.
Patients with acute-on-chronic liver failure (ACLF) represent a heterogeneous population. The aim of the study is to identify distinct groups according to the etiologies of precipitating events. A total of 405 ACLF patients were identified from 1,361 patients with cirrhosis with acute decompensation and categorized according to the types of acute insults. Clinical characteristics and prognosis between the hepatic group and extrahepatic group were compared, and the performance of prognostic models was tested in different groups. Two distinct groups (hepatic-ACLF and extrahepatic-ACLF) were identified among the ACLF population. Hepatic-ACLF was precipitated by hepatic insults and had relatively well-compensated cirrhosis with frequent liver and coagulation failure. In contrast, extrahepatic-ACLF was exclusively precipitated by extrahepatic insults, characterized by more severe underlying cirrhosis and high occurrence of extrahepatic organ failures (kidney, cerebral, circulation, and respiratory systems). Both groups had comparably high short-term mortality (28-day transplant-free mortality: 48.3% vs. 50.7%; P = 0.22); however, the extra-hepatic-ACLF group had significantly higher 90-day and 1-year mortality (90-day: 58.9% vs. 68.3%, P = 0.035; 1-year: 63.9% vs. 74.6%, P = 0.019). In hepatic-ACLF group, the integrated Model for End-Stage Liver Disease (iMELD) score had the highest area under the receiver operating characteristic curve (auROC = 0.787) among various prognostic models in predicting 28-day mortality, whereas CLIF-Consortium scores for ACLF patients (CLIF-C-ACLF) had the highest predictive value in the other group (auROC = 0.779).
ACLF precipitated by hepatic insults is distinct from ACLF precipitated by extrahepatic insults in clinical presentation and prognosis. The iMELD score may be a better predictor for hepatic-ACLF short-term prognosis, whereas CLIF-C-ACLF may be better for extrahepatic-ACLF patients.
急性肝衰竭（ACLF）患者是一个异质性群体。本研究旨在根据诱发事件的病因确定不同的亚组。
从 1361 例急性失代偿性肝硬化患者中确定了 405 例 ACLF 患者，并根据急性损伤的类型进行分类。比较了肝性和非肝性 ACLF 患者的临床特征和预后，并在不同组中检验了预后模型的性能。
在 ACLF 患者中发现了两个不同的亚组（肝性 ACLF 和非肝性 ACLF）。肝性 ACLF 由肝性损伤引起，代偿性较好的肝硬化，常伴有肝脏和凝血功能衰竭。相反，非肝性 ACLF 仅由肝外损伤引起，其特征是基础肝硬化更严重，肝外器官衰竭（肾、脑、循环和呼吸系统）发生率更高。两组短期死亡率均较高（28 天无移植死亡率：48.3%比 50.7%；P=0.22）；然而，非肝性 ACLF 组的 90 天和 1 年死亡率明显较高（90 天：58.9%比 68.3%，P=0.035；1 年：63.9%比 74.6%，P=0.019）。在肝性 ACLF 组中，各种预后模型中，终末期肝病模型（iMELD）评分预测 28 天死亡率的受试者工作特征曲线下面积（auROC）最高（0.787），而 ACLF 患者 CLIF-Consortium 评分（CLIF-C-ACLF）在另一组中具有最高的预测价值（auROC=0.779）。
由肝损伤引起的 ACLF 在临床表现和预后方面与由肝外损伤引起的 ACLF 不同。iMELD 评分可能是肝性 ACLF 短期预后的更好预测指标，而 CLIF-C-ACLF 可能更适合非肝性 ACLF 患者。
