Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand.
PLoS One. 2019 Jul 10;14(7):e0219516. doi: 10.1371/journal.pone.0219516. eCollection 2019.
Patients with acute-on-chronic liver failure (ACLF) precipitated by hepatic injury and extrahepatic insults had distinct clinical phenotypes, and prognosis. This study aimed to validate prognostic models for ACLF and to explore their discriminative abilities in ACLF population categorized by the etiologies of precipitating events.
This study collected data from 343 consecutive cirrhotic patients hospitalized with the diagnosis of ACLF according to the EASL-CLIF-Consortium definition. The discrimination abilities of prognostic models at the onset of ACLF were tested with the concordance index and area under the receiver operating characteristic curve.
Among the entire cohort, 103 patients survived with medical management, nine patients were transplanted, and 231 patients died without liver transplantation. The predictive accuracy of the Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) for 28-day mortality was similar to the CLIF Consortium Organ Failure (CLIF-C OF) but significantly higher than the CLIF Consortium ACLF, the Child-Turcotte-Pugh, the model for end-stage liver disease (MELD), the MELD-sodium, the integrated MELD, and the Acute Physiology and Chronic Health Evaluation II. Of note, 44 patients had acute hepatic insult triggering ACLF (hepatic-ACLF), 244 were exclusively precipitated by bacterial infection or gastrointestinal bleeding (extrahepatic-ACLF), and 55 cases had no any identifiable potential precipitating events. Patients with hepatic-ACLF had significantly higher 28-day mortality than extrahepatic-ACLF patients. The CLIF-SOFA and CLIF-C OF displayed the highest accuracy significantly outperforming other scoring systems in predicting mortality among patients with hepatic-ACLF and those with extrahepatic-ACLF.
The CLIF-SOFA and simpler CLIF-C OF are reliable measures of mortality risk in ACLF patients precipitated by either hepatic or extrahepatic insults. Both validated models could be used to stratify the risk of death and improve management of ACLF.
由肝损伤和肝外因素诱发的慢加急性肝衰竭（ACLF）患者具有不同的临床表型和预后。本研究旨在验证 ACLF 的预后模型，并探讨这些模型在根据诱发事件病因分类的 ACLF 患者人群中的区分能力。
本研究收集了 343 例连续住院的根据 EASL-CLIF-Consortium 定义诊断为 ACLF 的肝硬化患者的数据。使用一致性指数和接受者操作特征曲线下面积来测试预后模型在 ACLF 发病时的区分能力。
在整个队列中，103 例患者经内科治疗存活，9 例患者接受了移植，231 例患者在没有肝移植的情况下死亡。慢性肝脏衰竭-序贯器官衰竭评估（CLIF-SOFA）对 28 天死亡率的预测准确性与 CLIF 联盟器官衰竭（CLIF-C OF）相似，但明显高于 CLIF 联盟 ACLF、Child-Turcotte-Pugh、终末期肝病模型（MELD）、MELD 钠、综合 MELD 和急性生理学和慢性健康评估 II。值得注意的是，44 例患者因急性肝损伤诱发 ACLF（肝性 ACLF），244 例患者仅因细菌感染或胃肠道出血诱发 ACLF（肝外 ACLF），55 例患者无任何明确的潜在诱发因素。肝性 ACLF 患者的 28 天死亡率明显高于肝外 ACLF 患者。CLIF-SOFA 和 CLIF-C OF 在预测肝性 ACLF 和肝外 ACLF 患者死亡率方面表现出最高的准确性，明显优于其他评分系统。
CLIF-SOFA 和更简单的 CLIF-C OF 是预测由肝或肝外因素诱发的 ACLF 患者死亡率的可靠指标。这两种验证模型都可用于分层死亡风险，改善 ACLF 的管理。
