Department of Critical Care Medicine, University of Alberta, Edmonton, AB, Canada.
European Foundation for the study of Chronic Liver Failure, Barcelona, Spain.
Crit Care Med. 2018 Nov;46(11):1783-1791. doi: 10.1097/CCM.0000000000003369.
To evaluate the Chronic Liver Failure-Consortium Acute on Chronic Liver Failure score in acute on chronic liver failure patients admitted to ICUs from different global regions and compare discrimination ability with previously published scores.
Retrospective pooled analysis.
Academic ICUs in Canada (Edmonton, Vancouver) and Europe (Paris, Barcelona, Chronic liver failure/Acute-on-Chronic Liver Failure in Cirrhosis [CANONIC] study).
Sample of analysis of 867 cirrhotic patients with acute on chronic liver failure admitted to ICU. Cumulative incidence functions of death were estimated by acute on chronic liver failure grade at admission and at day 3. Survival discrimination abilities of Chronic Liver Failure-Consortium Acute on Chronic Liver Failure, Model for End-Stage Liver Disease, Acute Physiology and Chronic Health Evaluation II, and Child-Turcotte-Pugh scores were compared.
ICU admission for organ support.
At admission 169 subjects (19%) had acute on chronic liver failure 1, 302 (35%) acute on chronic liver failure 2, and 396 (46%) had acute on chronic liver failure 3 with 90-mortality rates of 33%, 40%, and 74%, respectively (p < 0.001). At admission, Chronic Liver Failure-Consortium Acute on Chronic Liver Failure demonstrated superior discrimination at 90 days compared with Acute Physiology and Chronic Health Evaluation II (n = 532; concordance index 0.67 vs 0.62; p = 0.0027) and Child-Turcotte-Pugh (n = 666; 0.68 vs 0.64; p = 0.0035), but not Model for End-Stage Liver Disease (n = 845; 0.68 vs 0.67; p = 0.3). A Chronic Liver Failure-Consortium Acute on Chronic Liver Failure score greater than 70 at admission or on day 3 was associated with 90-day mortality rates of approximately 90%. Ninety-day mortality in grade 3 acute on chronic liver failure patients at admission who demonstrated improvement by day 3 was 40% (vs 79% in patients who did not).
The Chronic Liver Failure-Consortium Acute on Chronic Liver Failure demonstrated better discrimination at day 28 and day 90 compared with Acute Physiology and Chronic Health Evaluation II and Child-Turcotte-Pugh. Patients who demonstrated clinical improvement post-ICU admission (e.g., acute on chronic liver failure 3 to 1 or 2) at day 3 had better outcomes than those who did not. In high-risk ICU patients (Chronic Liver Failure-Consortium Acute on Chronic Liver Failure > 70), decisions regarding transition to palliation should be explored between patient families and the ICU providers after a short trial of therapy.
评估慢性肝衰竭联盟急性肝衰竭评分在不同全球地区 ICU 收治的急性肝衰竭患者中的应用，并与先前发表的评分比较其鉴别能力。
回顾性汇总分析。
加拿大（埃德蒙顿、温哥华）和欧洲（巴黎、巴塞罗那）的学术 ICU。
分析了 867 例因急性肝衰竭入院 ICU 的肝硬化患者。通过入院时和第 3 天的急性肝衰竭分级，估计死亡的累积发生率函数。比较慢性肝衰竭联盟急性肝衰竭、终末期肝病模型、急性生理学和慢性健康评估 II 以及 Child-Turcotte-Pugh 评分的生存鉴别能力。
因器官支持而入住 ICU。
入院时，169 例（19%）患者为急性肝衰竭 1 级，302 例（35%）为急性肝衰竭 2 级，396 例（46%）为急性肝衰竭 3 级，90 日死亡率分别为 33%、40%和 74%（p<0.001）。入院时，慢性肝衰竭联盟急性肝衰竭评分在 90 天的鉴别能力优于急性生理学和慢性健康评估 II（n=532；一致性指数 0.67 比 0.62；p=0.0027）和 Child-Turcotte-Pugh（n=666；0.68 比 0.64；p=0.0035），但与终末期肝病模型（n=845；0.68 比 0.67；p=0.3）无差异。入院或第 3 天的慢性肝衰竭联盟急性肝衰竭评分>70 与 90 日死亡率约 90%相关。第 3 天从急性肝衰竭 3 级改善的患者 90 日死亡率为 40%（而未改善的患者为 79%）。
与急性生理学和慢性健康评估 II 及 Child-Turcotte-Pugh 相比，慢性肝衰竭联盟急性肝衰竭评分在第 28 天和第 90 天具有更好的鉴别能力。入院第 3 天有临床改善的患者（如急性肝衰竭 3 级转为 1 级或 2 级）预后优于无改善的患者。对于高危 ICU 患者（慢性肝衰竭联盟急性肝衰竭评分>70），在进行短暂的治疗试验后，应在患者家庭和 ICU 提供者之间探讨过渡到姑息治疗的决策。
