Chang Johannes, Bamarni Avend, Böhling Nina, Zhou Xin, Klein Leah-Marie, Meinke Jonathan, Duerr Georg Daniel, Lingohr Philipp, Wehner Sven, Brol Maximilian J, Rockstroh Jürgen K, Kalff Jörg C, Manekeller Steffen, Meyer Carsten, Spengler Ulrich, Jansen Christian, Arroyo Vicente, Strassburg Christian P, Trebicka Jonel, Praktiknjo Michael
Department of Internal Medicine IUniversity of BonnBonnGermany.
Heart CenterUniversity of BonnBonnGermany.
Hepatol Commun. 2021 Mar 26;5(7):1265-1277. doi: 10.1002/hep4.1712. eCollection 2021 Jul.
Acute-on-chronic liver failure (ACLF) is a syndrome associated with organ failure and high short-term mortality. Presence of ACLF at interventions, such as surgery or transjugular intrahepatic portosystemic shunt (TIPS), has been shown to determine outcome, but those interventions have also been attributed to precipitate ACLF in different studies. However, dedicated investigation for the risk of ACLF development in these interventions, especially in elective settings, has not been conducted. Patients with cirrhosis undergoing elective surgery were propensity score matched and compared to patients receiving TIPS. The primary endpoint was ACLF development within 28 days after the respective procedure. The secondary endpoint was 3-month and 1-year mortality. In total, 190 patients were included. Within 28 days, ACLF developed in 24% of the surgery and 3% of the TIPS cohorts, with the highest ACLF incidence between 3 and 8 days. By day 28 after the procedure, ACLF improved in the TIPS cohort. In both cohorts, patients developing ACLF within 28 days after surgery or TIPS placement showed significantly worse survival than patients without ACLF development at follow-up. After 12 months, mortality was significantly higher in the surgery cohort compared to the TIPS cohort (40% vs. 23%, respectively; = 0.031). Regression analysis showed a European Foundation Chronic Liver Failure Consortium acute decompensation (CLIF-C AD) score ≥50 and surgical procedure as independent predictors of ACLF development. CLIF-C AD score ≥50, C-reactive protein, and ACLF development within 28 days independently predicted 1-year mortality. Elective surgical interventions in patients with cirrhosis precipitate ACLF development and ultimately death, but TIPS plays a negligible role in the development of ACLF. Elective surgery in patients with CLIF-C AD ≥50 should be avoided, while the window of opportunity would be CLIF-C AD <50.
慢加急性肝衰竭（ACLF）是一种与器官衰竭及高短期死亡率相关的综合征。在诸如手术或经颈静脉肝内门体分流术（TIPS）等干预措施时出现ACLF已被证明可决定预后，但在不同研究中这些干预措施也被认为会促使ACLF发生。然而，尚未针对这些干预措施，尤其是在择期情况下ACLF发生风险进行专门研究。对接受择期手术的肝硬化患者进行倾向评分匹配，并与接受TIPS的患者进行比较。主要终点是各自手术后28天内发生ACLF。次要终点是3个月和1年死亡率。总共纳入了190例患者。在28天内，手术组中有24%发生ACLF，TIPS组中有3%发生ACLF，ACLF发生率最高在术后3至8天。到术后第28天，TIPS组中ACLF有所改善。在两个队列中，术后或TIPS置入后28天内发生ACLF的患者在随访时的生存率明显低于未发生ACLF的患者。12个月后，手术组的死亡率明显高于TIPS组（分别为40%和23%；P = 0.031）。回归分析显示，欧洲肝脏研究学会慢性肝衰竭协会急性失代偿（CLIF-C AD）评分≥50以及手术操作是ACLF发生的独立预测因素。CLIF-C AD评分≥50、C反应蛋白以及术后28天内发生ACLF可独立预测1年死亡率。肝硬化患者的择期手术干预会促使ACLF发生并最终导致死亡，但TIPS在ACLF发生中起的作用可忽略不计。对于CLIF-C AD≥50的患者应避免择期手术，而机会窗口应为CLIF-C AD<50。
