Kedia Saurabh, Mahapatra Soumya J, Nayak Baibaswata, Gunjan Deepak, Thakur Bhaskar, Acharya Subrat K
Departments of *Gastroenterology †Biostatistics, All India Institute of Medical Sciences, New Delhi, India.
J Clin Gastroenterol. 2017 Sep;51(8):734-741. doi: 10.1097/MCG.0000000000000823.
Acute-on-chronic liver failure (ACLF) may be precipitated by various hepatic insults. The present study evaluated the outcomes of ACLF with different acute insults.
A total of 368 ACLF patients were included. Data collected included etiologies of acute hepatic insult and underlying chronic liver disease, and organ failure. Model for end-stage liver disease (MELD), chronic liver failure consortium (CLIF)-C ACLF, and acute physiology and chronic health evaluation (APACHE) II scores were calculated. Predictors of survival were assessed by the Cox proportional hazard model.
The most frequent acute insult was active alcohol consumption [150 (40.8%) patients], followed by hepatitis B virus (HBV) [71 (19.3%) patients], hepatitis E virus (HEV) superinfection [45 (12.2%) patients], autoimmune hepatitis flare [17 (4.6%) patients], antituberculosis drugs [16 (4.3%) patients], and hepatitis A virus superinfection [2 (0.5%) patients]; 67 (18.2%) cases were cryptogenic. Alcohol-ACLF and cryptogenic-ACLF were more severe. Median CLIF-C, MELD, and APACHE II scores in alcohol-ACLF and cryptogenic-ACLF were significantly higher than those in HBV-ACLF and HEV-ACLF (CLIF-C: 47.1, 47.4 vs. 42.9, 42.0, P=0.002; MELD: 29, 29.9 vs. 28.9, 25.2, P=0.02; APACHE II: 16.5, 18.0 vs. 12, 14, P<0.001, respectively). Frequencies of kidney and brain failures were also higher in alcohol/cryptogenic-ACLF than in HBV/HEV-ACLF (kidney failure: 35.3%/34.3% vs. 23.9%/11.1%, P=0.009; brain failure: 26.0%/22.4% vs. 15.5%/4.4%, P=0.01, respectively). Mortality in the alcohol-ACLF group was the highest (64.0%), followed by that in the cryptogenic-ACLF (62.7%), HBV-ACLF (45.1%), and HEV-ACLF (17.8%) groups (P<0.001). In multivariable analysis, alcohol-ACLF had significantly higher mortality compared with HEV-ACLF (hazard ratio, 3.06; 95% confidence interval, 1.10-8.49, P=0.03).
Alcohol/cryptogenic-ACLF had more severe phenotypic presentation, more incidence of organ failures, and higher mortality compared with HEV/HBV-ACLF. Alcohol-ACLF had the highest mortality, whereas HEV-ACLF had the best survival.
慢性肝病急性肝衰竭（ACLF）可能由各种肝脏损伤引发。本研究评估了不同急性损伤所致ACLF的预后情况。
共纳入368例ACLF患者。收集的数据包括急性肝损伤的病因、潜在慢性肝病以及器官衰竭情况。计算终末期肝病模型（MELD）、慢性肝衰竭协作组（CLIF）-C ACLF评分以及急性生理与慢性健康状况评估（APACHE）II评分。通过Cox比例风险模型评估生存预测因素。
最常见的急性损伤是大量饮酒[150例（40.8%）患者]，其次是乙型肝炎病毒（HBV）感染[71例（19.3%）患者]、戊型肝炎病毒（HEV）重叠感染[45例（12.2%）患者]、自身免疫性肝炎发作[17例（4.6%）患者]、抗结核药物[16例（4.3%）患者]以及甲型肝炎病毒重叠感染[2例（0.5%）患者]；67例（18.2%）病例病因不明。酒精性ACLF和不明原因ACLF病情更严重。酒精性ACLF和不明原因ACLF的CLIF-C、MELD及APACHE II评分中位数显著高于HBV-ACLF和HEV-ACLF（CLIF-C：47.1、47.4对42.9、42.0，P = 0.002；MELD：29、29.9对28.9、25.2，P = 0.02；APACHE II：16.5、18.0对12、14，P均<0.001）。酒精性/不明原因ACLF组的肾脏和脑衰竭发生率也高于HBV/HEV-ACLF组（肾衰竭：35.3%/34.3%对23.9%/11.1%，P = 0.009；脑衰竭：26.0%/22.4%对15.5%/4.4%，P = 0.01）。酒精性ACLF组死亡率最高（64.0%），其次是不明原因ACLF组（62.7%）、HBV-ACLF组（45.1%）和HEV-ACLF组（,17.8%）（P<0.001）。多变量分析显示，与HEV-ACLF相比，酒精性ACLF死亡率显著更高（风险比，3.06；95%置信区间，1.10 - 8.49，P = 0.03）。
与HEV/HBV-ACLF相比，酒精性/不明原因ACLF临床表现更严重，器官衰竭发生率更高，死亡率也更高。酒精性ACLF死亡率最高，而HEV-ACLF生存率最佳。
