Zaccherini Giacomo, Baldassarre Maurizio, Bartoletti Michele, Tufoni Manuel, Berardi Sonia, Tamè Mariarosa, Napoli Lucia, Siniscalchi Antonio, Fabbri Angela, Marconi Lorenzo, Antognoli Agnese, Iannone Giulia, Domenicali Marco, Viale Pierluigi, Trevisani Franco, Bernardi Mauro, Caraceni Paolo
Department of Medical and Surgical Sciences - University of Bologna, Italy.
Centre for Applied Biomedical Research (CRBA), University of Bologna, Italy.
JHEP Rep. 2019 Aug 1;1(4):270-277. doi: 10.1016/j.jhepr.2019.07.005. eCollection 2019 Oct.
Nosocomial acute-on-chronic liver failure (nACLF) develops in at least 10% of patients with cirrhosis hospitalized for acute decompensation (AD), greatly worsening their prognosis. In this prospective observational study, we aimed to identify rapidly obtainable predictors at admission, which allow for the early recognition and stratification of patients at risk of nACLF.
A total of 516 consecutive patients hospitalized for AD of cirrhosis were screened: those who did not present ACLF at admission (410) were enrolled and surveilled for the development of nACLF.
Fifty-nine (14%) patients developed nALCF after a median of 7 (IQR 4-18) days. At admission, they presented a more severe disease and higher degrees of systemic inflammation and anemia than those (351; 86%) who remained free from nACLF. Competing risk multivariable regression analysis showed that baseline MELD score (sub-distribution hazard ratio [sHR] 1.15; 95% CI 1.10-1.21; 0.001), hemoglobin level (sHR 0.81; 95% CI 0.68-0.96; 0.018), and leukocyte count (sHR 1.11; 95% CI 1.06-1.16; 0.001) independently predicted nACLF. Their optimal cut-off points, determined by receiver-operating characteristic curve analysis, were: 13 points for MELD score, 9.8 g/dl for hemoglobin, and 5.6x10/L for leukocyte count. These thresholds were used to stratify patients according to the cumulative incidence of nACLF, being 0, 6, 21 and 59% in the presence of 0, 1, 2 or 3 risk factors (0.001). Nosocomial bacterial infections only increased the probability of developing nACLF in patients with at least 1 risk factor, rising from 3% to 29%, 16% to 50% and 52% to 83% in patients with 1, 2 or 3 risk factors, respectively.
Easily available laboratory parameters, related to disease severity, systemic inflammation, and anemia, can be used to identify, at admission, hospitalized patients with AD at increased risk of developing nACLF.
More than 10% of patients with cirrhosis hospitalized because of an acute decompensation develop acute-on-chronic liver failure, which is associated with high short-term mortality, during their hospital stay. We found that the combination of 3 easily obtainable variables (model for end-stage liver disease score, leukocyte count and hemoglobin level) help to identify and stratify patients according to their risk of developing nosocomial acute-on-chronic liver failure, from nil to 59%. Moreover, if a nosocomial bacterial infection occurs, such an incidence proportionally increases from nil to 83%. This simple approach helps to identify patients at risk of developing nosocomial acute-on-chronic liver failure at admission to hospital, enabling clinicians to put in place preventive measures.
至少10%因急性失代偿（AD）住院的肝硬化患者会发生医院获得性慢加急性肝衰竭（nACLF），这会大大恶化他们的预后。在这项前瞻性观察性研究中，我们旨在确定入院时可快速获得的预测指标，以便早期识别和分层有nACLF风险的患者。
共筛查了516例因肝硬化AD住院的连续患者：那些入院时未出现ACLF的患者（410例）被纳入并监测nACLF的发生情况。
59例（14%）患者在中位时间7天（四分位间距4 - 18天）后发生了nALCF。入院时，他们的病情比未发生nACLF的患者（351例；86%）更严重，全身炎症和贫血程度更高。竞争风险多变量回归分析显示，基线终末期肝病模型（MELD）评分（亚分布风险比[sHR] 1.15；95%置信区间1.10 - 1.21；P < 0.001）、血红蛋白水平（sHR 0.81；95%置信区间0.68 -
0.96；P = 0.018）和白细胞计数（sHR 1.11；95%置信区间1.06 - 1.16；P < 0.001）独立预测nACLF。通过受试者工作特征曲线分析确定的它们的最佳切点分别为：MELD评分为13分，血红蛋白为9.8 g/dl，白细胞计数为5.6×10⁹/L。这些阈值用于根据nACLF的累积发生率对患者进行分层，存在0、1、2或3个风险因素时，发生率分别为0、6%、21%和59%（P < 0.001）。医院获得性细菌感染仅增加了至少有1个风险因素的患者发生nACLF的概率，在有1、2或3个风险因素的患者中，发生率分别从3%升至29%、16%升至50%和52%升至83%。
与疾病严重程度、全身炎症和贫血相关的易于获得的实验室参数可用于在入院时识别有发生nACLF风险增加的因AD住院的患者。
超过10%因急性失代偿住院的肝硬化患者在住院期间会发生慢加急性肝衰竭，这与高短期死亡率相关。我们发现3个易于获得的变量（终末期肝病模型评分、白细胞计数和血红蛋白水平）的组合有助于根据患者发生医院获得性慢加急性肝衰竭的风险进行识别和分层，风险从0到59%。此外，如果发生医院获得性细菌感染，这种发生率会相应地从0升至83%。这种简单方法有助于在入院时识别有发生医院获得性慢加急性肝衰竭风险的患者，使临床医生能够采取预防措施。
