Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium.
Hospital Clínic, Barcelona, Spain.
Hepatology. 2015 Jul;62(1):243-52. doi: 10.1002/hep.27849. Epub 2015 May 29.
Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation (AD) of cirrhosis, organ failure(s), and high 28-day mortality. We investigated whether assessments of patients at specific time points predicted their need for liver transplantation (LT) or the potential futility of their care. We assessed clinical courses of 388 patients who had ACLF at enrollment, from February through September 2011, or during early (28-day) follow-up of the prospective multicenter European Chronic Liver Failure (CLIF) ACLF in Cirrhosis study. We assessed ACLF grades at different time points to define disease resolution, improvement, worsening, or steady or fluctuating course. ACLF resolved or improved in 49.2%, had a steady or fluctuating course in 30.4%, and worsened in 20.4%. The 28-day transplant-free mortality was low-to-moderate (6%-18%) in patients with nonsevere early course (final no ACLF or ACLF-1) and high-to-very high (42%-92%) in those with severe early course (final ACLF-2 or -3) independently of initial grades. Independent predictors of course severity were CLIF Consortium ACLF score (CLIF-C ACLFs) and presence of liver failure (total bilirubin ≥12 mg/dL) at ACLF diagnosis. Eighty-one percent had their final ACLF grade at 1 week, resulting in accurate prediction of short- (28-day) and mid-term (90-day) mortality by ACLF grade at 3-7 days. Among patients that underwent early LT, 75% survived for at least 1 year. Among patients with ≥4 organ failures, or CLIF-C ACLFs >64 at days 3-7 days, and did not undergo LT, mortality was 100% by 28 days.
Assessment of ACLF patients at 3-7 days of the syndrome provides a tool to define the emergency of LT and a rational basis for intensive care discontinuation owing to futility.
慢加急性肝衰竭（ACLF）的特征为肝硬化急性失代偿（AD）、器官衰竭和 28 天死亡率高。我们研究了特定时间点患者评估是否可以预测其肝移植（LT）需求或其治疗无效的可能性。我们评估了 2011 年 2 月至 9 月 ACLF 入组或前瞻性多中心欧洲慢性肝衰竭（CLIF）ACLF 肝硬化研究早期（28 天）随访期间的 388 例 ACLF 患者的临床病程。我们评估了不同时间点的 ACLF 分级以确定疾病的缓解、改善、恶化或稳定或波动。49.2%的患者 ACLF 缓解或改善，30.4%的患者稳定或波动，20.4%的患者恶化。非严重早期病程（最终无 ACLF 或 ACLF-1）患者 28 天无 LT 死亡率为低至中度（6%-18%），而严重早期病程（最终 ACLF-2 或 -3）患者为高至极高（42%-92%），与初始分级无关。病程严重程度的独立预测因子为 CLIF 联盟 ACLF 评分（CLIF-C ACLFs）和 ACLF 诊断时的肝功能衰竭（总胆红素≥12mg/dL）。81%的患者在第 1 周确定最终 ACLF 分级，因此在第 3-7 天通过 ACLF 分级准确预测短期（28 天）和中期（90 天）死亡率。在早期接受 LT 的患者中，75%的患者至少存活 1 年。在≥4 个器官衰竭或第 3-7 天的 CLIF-C ACLFs>64 的患者中，且未接受 LT 的患者，28 天死亡率为 100%。
在综合征的 3-7 天评估 ACLF 患者提供了一个定义 LT 紧急情况的工具，并为因无效而停止强化治疗提供了合理依据。
