Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, Texas, USA.
Liver Int. 2022 Dec;42(12):2781-2790. doi: 10.1111/liv.15449. Epub 2022 Oct 17.
Emerging evidence has identified hypochloremia as an independent predictor for mortality in multiple conditions including cirrhosis. Acute liver failure (ALF) is frequently complicated by electrolyte abnormalities. We investigated the prognostic value of hypochloremia in a large cohort of ALF patients from North America.
The Acute Liver Failure Study Group (ALFSG) registry is a longitudinal cohort study involving 2588 ALF patients enrolled prospectively from 32 North American academic centres. The primary outcome was a composite of 21-day all-cause mortality or requirement for liver transplantation (death/LT).
Patients with hypochloremia (<98 mEq/L) had a significantly higher 21-day mortality rate (42.1%) compared with those with normal (27.5%) or high (>107 mEq/L) chloride (28.0%) (p < .001). There was lower transplant-free cumulative survival in the hypochloremic group than in the normo- or hyper-chloremic groups (log-rank, χ 24.2, p < .001). Serum chloride was inversely associated with the hazard of 21-day death/LT with multivariable adjustment for known prognostic factors (adjusted hazard ratio [aHR]: 0.977; 95% CI: 0.969-0.985; p < .001). Adding chloride to the ALFSG Prognostic Index more accurately predicted risk of death/LT in 19% of patients (net reclassification improvement [NRI] = 0.19, 95% CI: 0.13-0.25) but underestimated the probability of transplant-free survival in 34% of patients (NRI = -0.34, 95% CI: -0.39 to -0.28).
Hypochloremia is a novel independent adverse prognostic factor in ALF. A new ALFSG-Cl Prognostic Index may improve the sensitivity to identify patients at risk for death without LT.
越来越多的证据表明，低氯血症是包括肝硬化在内的多种疾病患者死亡率的独立预测因素。急性肝衰竭（ALF）常伴有电解质异常。我们对来自北美的大量 ALF 患者进行了一项研究，旨在探讨低氯血症的预后价值。
急性肝衰竭研究组（ALFSG）登记处是一项纵向队列研究，共纳入 32 个北美学术中心前瞻性纳入的 2588 名 ALF 患者。主要终点为 21 天全因死亡率或需要肝移植（死亡/肝移植）的复合终点。
低氯血症（<98 mEq/L）患者 21 天死亡率（42.1%）明显高于正常氯血症（27.5%）或高氯血症（>107 mEq/L）（28.0%）患者（p <.001）。低氯血症组的无移植累积生存率低于正常氯血症或高氯血症组（对数秩检验，χ24.2，p <.001）。在对已知预后因素进行多变量调整后，血清氯与 21 天死亡/肝移植的风险呈负相关（调整后的危险比[aHR]：0.977；95%可信区间：0.969-0.985；p <.001）。将氯加入 ALFSG 预后指数可更准确地预测 19%患者的死亡/肝移植风险（净重新分类改善[NRI]为 0.19，95%可信区间：0.13-0.25），但低估了 34%患者的无移植生存率（NRI为-0.34，95%可信区间：-0.39 至-0.28）。
低氯血症是 ALF 的一种新的独立不良预后因素。一种新的 ALFSG-Cl 预后指数可能会提高识别无 LT 死亡风险患者的敏感性。
