Department of Medicine University of Miami Miller School of Medicine Miami FL Division of Digestive Health and Liver Diseases University of Miami Miller School of Medicine Miami FL Department of Medicine Corporal Michael J. Crescenz Veterans Affairs Medical Center Philadelphia PA Division of Gastroenterology and HepatologyPerelman School of Medicine University of Pennsylvania Philadelphia PA Leonard David Institute of Health Economics University of Pennsylvania Philadelphia PA Division of Gastroenterology and Comprehensive Transplant Center Cedars-Sinai Medical Center Los Angeles CA Division of Digestive Diseases Yale University School of Medicine New Haven CT VA Connecticut Healthcare System West Haven CT.
Liver Transpl. 2021 Jan;27(1):16-26. doi: 10.1002/lt.25896. Epub 2020 Oct 28.
There is significant interest in identifying risk factors associated with acute-on-chronic liver failure (ACLF). In transplant candidates, frailty predicts wait-list mortality and posttransplant outcomes. However, the impact of frailty on ACLF development and mortality is unknown. This was a retrospective study of US veterans with cirrhosis identified between 2008 and 2016. First hospitalizations were characterized as ACLF or non-ACLF admissions. Prehospitalization patient frailty was ascertained using a validated score based on administrative coding data. We used logistic regression to investigate the impact of an increasing frailty score on the odds of ACLF hospitalization and short-term ACLF mortality. Cox regression was used to analyze the association between frailty and longterm survival from hospitalization. We identified 16,561 cirrhosis hospitalizations over a median follow-up of 4.19 years (interquartile range, 2.47-6.34 years). In adjusted models, increasing frailty score was associated with significantly increased odds of ACLF hospitalization versus non-ACLF hospitalization (odds ratio, 1.03 per point; 95% CI 1.02-1.03; P < 0.001). By contrast, frailty score was not associated with ACLF 28- or 90-day mortality (P = 0.13 and P = 0.33, respectively). In an adjusted Cox analysis of all hospitalizations, increasing frailty scores were associated with poorer longterm survival from the time of hospitalization (hazard ratio, 1.02 per 5 points; 95% confidence interval, 1.01-1.03; P = 0.004). Frailty increases the likelihood of ACLF hospitalization among patients with cirrhosis, but it does not impact short-term ACLF mortality. These findings have implications for clinicians caring for frail outpatients with cirrhosis, including tailored follow-up, risk mitigation strategies, and possible expedited transplant evaluation.
人们对确定与慢加急性肝衰竭（ACLF）相关的风险因素非常感兴趣。在移植候选者中，衰弱预测等待名单死亡率和移植后结局。然而，衰弱对 ACLF 发展和死亡率的影响尚不清楚。这是一项在美国退伍军人中进行的回顾性研究，这些退伍军人在 2008 年至 2016 年间被诊断为肝硬化。首次住院被定义为 ACLF 或非 ACLF 住院。使用基于行政编码数据的验证评分来确定住院前患者的衰弱程度。我们使用逻辑回归来研究衰弱评分增加对 ACLF 住院和短期 ACLF 死亡率的几率的影响。Cox 回归用于分析衰弱与从住院到长期生存的关联。我们在中位随访时间为 4.19 年（四分位距，2.47-6.34 年）的情况下确定了 16561 例肝硬化住院患者。在调整模型中，与非 ACLF 住院相比，衰弱评分增加与 ACLF 住院的几率显著增加相关（优势比，每点 1.03；95%置信区间，1.02-1.03；P <0.001）。相比之下，衰弱评分与 ACLF 28 天或 90 天死亡率无关（P=0.13 和 P=0.33）。在所有住院患者的调整 Cox 分析中，衰弱评分增加与从住院时间开始的长期生存较差相关（风险比，每 5 分增加 1.02；95%置信区间，1.01-1.03；P=0.004）。衰弱增加了肝硬化患者 ACLF 住院的可能性，但不影响 ACLF 的短期死亡率。这些发现对照顾肝硬化衰弱门诊患者的临床医生具有重要意义，包括量身定制的随访、风险缓解策略和可能加快移植评估。
