Gupta Tarana, Dhiman Radha K, Rathi Sahaj, Agrawal Swastik, Duseja Ajay, Taneja Sunil, Chawla Yogesh
Department of Hepatology, Postgraduate Institute of Medical Education & Research, Chandigarh 160012, India.
J Clin Exp Hepatol. 2017 Mar;7(1):9-15. doi: 10.1016/j.jceh.2016.10.006. Epub 2016 Oct 29.
To study the differences in outcome and predictors of mortality in acute-on-chronic liver failure (ACLF) precipitated by hepatic or extrahepatic insults.
Consecutive patients of cirrhosis with acute decompensation were prospectively included and followed up for 90 days from admission. ACLF was defined based on chronic liver failure (CLIF) acute-on-chronic liver failure in cirrhosis (CANONIC study) criteria. Acute worsening due to acute viral hepatitis A and E, hepatitis B flare, alcoholic hepatitis, autoimmune hepatitis flare, or drug-induced liver injury were categorized as hepatic ACLF and that due to bacterial infection, upper gastrointestinal bleed or surgery as extrahepatic ACLF. Patients with both hepatic and extrahepatic insults were included in combined insult group.
Of 179 patients of acute decompensation, 122 had ACLF (hepatic insults 47 and extrahepatic insults 51). Alcohol (64.8%) was the most common etiology of cirrhosis while infection (36%) was the most common acute insult followed by alcoholic hepatitis (24.6%). Higher proportion of extrahepatic ACLF patients had history of prior decompensation than hepatic ACLF patients (62.7% vs. 27.7%, < 0.001). There was no difference in mortality among hepatic and extrahepatic ACLF groups at 28 and 90 days (53.2% vs. 56.9%, = 0.715 and 85% vs. 74.5%, = 0.193, respectively). Area under receiver-operating curve (AUROC) for 28-day mortality in extrahepatic ACLF group was 0.788, 0.724, 0.718, 0.634, and 0.726 and in hepatic-ACLF group was 0.786, 0.625, 0.802, 0.761, and 0.648 for chronic liver failure-sequential organ failure assessment (CLIF-SOFA), model for end stage liver disease (MELD), integrated MELD score (iMELD), acute physiology and chronic health evaluation score (APACHE-II), and Child-Turcotte-Pugh score scores, respectively.
There is no difference in mortality among hepatic and extrahepatic ACLF groups at 28 and 90 days. iMELD and CLIF-SOFA have highest AUROC to predict 28-day mortality in hepatic and extrahepatic ACLF groups, respectively.
研究由肝脏或肝外损伤引发的慢加急性肝衰竭（ACLF）的预后差异及死亡预测因素。
前瞻性纳入肝硬化急性失代偿的连续患者，并从入院起随访90天。根据肝硬化慢加急性肝衰竭（CLIF）（CANONIC研究）标准定义ACLF。因急性甲型和戊型病毒性肝炎、乙型肝炎发作、酒精性肝炎、自身免疫性肝炎发作或药物性肝损伤导致的急性恶化被归类为肝脏性ACLF，因细菌感染、上消化道出血或手术导致的急性恶化被归类为肝外性ACLF。同时存在肝脏和肝外损伤的患者被纳入合并损伤组。
在179例急性失代偿患者中，122例患有ACLF（肝脏损伤47例，肝外损伤51例）。酒精（64.8%）是肝硬化最常见的病因，而感染（36%）是最常见的急性损伤，其次是酒精性肝炎（24.6%）。肝外ACLF患者既往失代偿史的比例高于肝脏ACLF患者（62.7%对27.7%，<0.001）。肝脏性和肝外性ACLF组在28天和90天时的死亡率无差异（分别为53.2%对56.9%，P = 0.715；85%对74.5%，P = 0.193）。肝外ACLF组28天死亡率的受试者工作特征曲线下面积（AUROC），慢性肝衰竭序贯器官衰竭评估（CLIF-SOFA）为0.788、终末期肝病模型（MELD）为0.724、综合MELD评分（iMELD）为0.718、急性生理与慢性健康评估评分（APACHE-II）为0.634、Child-Turcotte-Pugh评分（CTP）为0.726；肝脏性ACLF组相应评分的AUROC分别为0.786、0.625、0.802、0.761和0.648。
肝脏性和肝外性ACLF组在28天和90天时的死亡率无差异。iMELD和CLIF-SOFA分别在预测肝脏性和肝外性ACLF组28天死亡率方面具有最高的AUROC。
