Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India.
Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
Hepatol Int. 2022 Oct;16(5):1234-1243. doi: 10.1007/s12072-022-10372-1. Epub 2022 Jul 18.
Limited data exist regarding outcomes of acute variceal bleeding (AVB) in patients with acute-on-chronic liver failure (ACLF), especially in those with hepatic failure. We evaluated the outcomes of AVB in patients with ACLF in a multinational cohort of APASL ACLF Research Consortium (AARC).
Prospectively maintained data from AARC database on patients with ACLF who developed AVB (ACLF-AVB) was analysed. This data included demographic profile, severity of liver disease, and rebleeding and mortality in 6 weeks. These outcomes were compared with a propensity score matched (PSM) cohort of ACLF matched for severity of liver disease (MELD, AARC score) without AVB (ACLF without AVB).
Of the 4434 ACLF patients, the outcomes in ACLF-AVB (n = 72) [mean age-46 ± 10.4 years, 93% males, 66% with alcoholic liver disease, 65% with alcoholic hepatitis, AARC score: 10.1 ± 2.2, MELD score: 34 (IQR: 27-40)] were compared with a PSM cohort selected in a ratio of 1:2 (n = 143) [mean age-44.9 ± 12.5 years, 82.5% males, 48% alcoholic liver disease, 55.7% alcoholic hepatitis, AARC score: 9.4 ± 1.5, MELD score: 32 (IQR: 24-40)] of ACLF-without AVB. Despite PSM, ACLF patients with AVB had a higher baseline HVPG than without AVB (25.00 [IQR: 23.00-28.00] vs. 17.00 [15.00-21.75] mmHg; p = 0.045). The 6-week mortality in ACLF patients with or without AVB was 70.8% and 53.8%, respectively (p = 0.025). The 6-week rebleeding rate was 23% in ACLF-AVB. Presence of ascites [hazard ratio (HR) 2.2 (95% CI 1.03-9.8), p = 0.026], AVB [HR 1.9 (95% CI 1.2-2.5, p = 0.03)], and MELD score [HR 1.7 (95% CI 1.1-2.1), p = 0.001] independently predicted mortality in the overall ACLF cohort.
Development of AVB confers poor outcomes in patients with ACLF with a high 6-week mortality. Elevated HVPG at baseline represents a potential risk factor for future AVB in ACLF.
关于伴有慢加急性肝衰竭（ACLF）的急性静脉曲张出血（AVB）患者的结局，尤其是肝衰竭患者的结局，相关数据有限。我们通过亚太肝脏研究学会 ACLF 研究联盟（AARC）的一个多国家队列评估了 ACLF 患者中 AVB 的结局。
分析了 AARC 数据库中记录的伴有 ACLF 且发生 AVB（ACLF-AVB）的患者的前瞻性数据（n=72）。该数据包括人口统计学特征、肝脏疾病严重程度、以及 6 周内的再出血和死亡率。这些结局与未发生 AVB（ACLF 无 AVB）的 ACLF 患者（n=143）进行了比较，后者是按照肝脏疾病严重程度（MELD、AARC 评分）进行倾向性评分匹配（PSM）的。
在 4434 例 ACLF 患者中，ACLF-AVB（n=72）[平均年龄 46±10.4 岁，93%为男性，66%为酒精性肝病，65%为酒精性肝炎，AARC 评分：10.1±2.2，MELD 评分：34（IQR：27-40）]的结局与 PSM 队列（n=143）[平均年龄 44.9±12.5 岁，82.5%为男性，48%为酒精性肝病，55.7%为酒精性肝炎，AARC 评分：9.4±1.5，MELD 评分：32（IQR：24-40）]进行了比较。尽管进行了 PSM，但与 ACLF 无 AVB 患者相比，ACLF 合并 AVB 患者的基线 HVPG 更高（25.00 [IQR：23.00-28.00] vs. 17.00 [15.00-21.75] mmHg；p=0.045）。ACLF 患者无论是否发生 AVB，6 周死亡率分别为 70.8%和 53.8%（p=0.025）。ACLF-AVB 患者的 6 周再出血率为 23%。腹水存在（风险比[HR]2.2（95%可信区间 1.03-9.8），p=0.026）、AVB（HR 1.9（95%可信区间 1.2-2.5，p=0.03））和 MELD 评分（HR 1.7（95%可信区间 1.1-2.1），p=0.001）独立预测了整体 ACLF 队列的死亡率。
ACLF 患者发生 AVB 预示着预后不良，6 周死亡率较高。基线 HVPG 升高代表 ACLF 患者未来发生 AVB 的潜在危险因素。
