Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center, Houston, TX, USA; VA HSR&D Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA; Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA.
Department of Critical Care Medicine and Division of Gastroenterology (Liver Unit), University of Alberta, Canada.
J Hepatol. 2023 Sep;79(3):717-727. doi: 10.1016/j.jhep.2023.05.028. Epub 2023 Jun 12.
BACKGROUND & AIMS: Twenty-eight-day mortality ranges from 30-90% in patients with acute-on-chronic liver failure grades 2/3 (severe ACLF). Though liver transplantation (LT) has demonstrated a survival benefit, the scarcity of donor organs and uncertainty regarding post-LT mortality among patients with severe ACLF may cause hesitancy. We developed and externally validated a model to predict 1-year post-LT mortality in severe ACLF, called the Sundaram ACLF-LT-Mortality (SALT-M) score, and estimated the median length of stay (LoS) after LT (ACLF-LT-LoS).
In 15 LT centers in the US, we retrospectively identified a cohort of patients with severe ACLF transplanted between 2014-2019, followed up to Jan'2022. Candidate predictors included demographics, clinical and laboratory values, and organ failures. We selected predictors in the final model using clinical criteria and externally validated them in two French cohorts. We provided measures of overall performance, discrimination, and calibration. We used multivariable median regression to estimate LoS after adjusting for clinically relevant factors.
We included 735 patients, of whom 521 (70.8%) had severe ACLF (120 ACLF-3, external cohort). The median age was 55 years, and 104 with severe ACLF (19.9%) died within 1-year post-LT. Our final model included age >50 years, use of 1/≥2 inotropes, presence of respiratory failure, diabetes mellitus, and BMI (continuous). The c-statistic was 0.72 (derivation) and 0.80 (validation), indicating adequate discrimination and calibration based on the observed/expected probability plots. Age, respiratory failure, BMI, and presence of infection independently predicted median LoS.
The SALT-M score predicts mortality within 1-year after LT in patients with ACLF. The ACLF-LT-LoS score predicted median post-LT stay. Future studies using these scores could assist in determining transplant benefits.
Liver transplantation (LT) may be the only life-saving procedure available to patients with acute-on-chronic liver failure (ACLF), but clinically instability can augment the perceived risk of post-transplant mortality at 1 year. We developed a parsimonious score with clinically and readily available parameters to objectively assess 1-year post-LT survival and predict median length of stay after LT. We developed and externally validated a clinical model called the Sundaram ACLF-LT-Mortality score in 521 US patients with ACLF with 2 or ≥3 organ failure(s) and 120 French patients with ACLF grade 3. The c-statistic was 0.72 in the development cohort and 0.80 in the validation cohort. We also provided an estimation of the median length of stay after LT in these patients. Our models can be used in discussions on the risks/benefits of LT in patients listed with severe ACLF. Nevertheless, the score is far from perfect and other factors, such as patient's preference and center-specific factors, need to be considered when using these tools.
在 2/3 级（严重 ACLF）慢加急性肝衰竭患者中，28 天死亡率范围为 30%-90%。尽管肝移植（LT）已显示出生存获益，但严重 ACLF 患者 LT 后供体器官的稀缺性和死亡率的不确定性可能导致犹豫不决。我们开发并在外部验证了一种预测严重 ACLF 患者 LT 后 1 年死亡率的模型，称为 Sundaram ACLF-LT-死亡率（SALT-M）评分，并估计了 LT 后中位住院时间（ACLF-LT-LoS）。
在美国 15 个 LT 中心，我们回顾性地确定了 2014-2019 年期间接受 LT 的严重 ACLF 患者队列，并随访至 2022 年 1 月。候选预测因子包括人口统计学、临床和实验室值以及器官衰竭。我们使用临床标准在最终模型中选择预测因子，并在两个法国队列中进行外部验证。我们提供了整体性能、区分度和校准度的衡量标准。我们使用多变量中位数回归来调整临床相关因素后估计 LT 后的住院时间。
我们纳入了 735 名患者，其中 521 名（120 名 ACLF-3，外部队列）患有严重 ACLF。中位年龄为 55 岁，104 名严重 ACLF 患者（19.9%）在 LT 后 1 年内死亡。我们的最终模型包括年龄>50 岁、使用 1/≥2 种正性肌力药、存在呼吸衰竭、糖尿病和 BMI（连续变量）。C 统计量为 0.72（推导）和 0.80（验证），表明根据观察到的/预期的概率图，区分度和校准度适中。年龄、呼吸衰竭、BMI 和感染的存在独立预测中位 LOS。
SALT-M 评分可预测 ACLF 患者 LT 后 1 年内的死亡率。ACLF-LT-LoS 评分预测 LT 后的中位住院时间。未来使用这些评分的研究可以帮助确定移植的益处。
肝移植（LT）可能是急性慢性肝衰竭（ACLF）患者唯一的救命手术，但临床不稳定可能会增加术后 1 年死亡率的感知风险。我们开发了一种简洁的评分，具有临床和易于获得的参数，可客观评估 LT 后 1 年的生存情况，并预测 LT 后中位住院时间。我们在 521 名患有 ACLF 伴 2 或≥3 个器官衰竭和 120 名患有 ACLF 3 级的美国 ACLF 患者中开发并外部验证了一种名为 Sundaram ACLF-LT-Mortality 评分的临床模型。C 统计量在推导队列中为 0.72，在验证队列中为 0.80。我们还提供了这些患者 LT 后中位住院时间的估计值。我们的模型可用于讨论严重 ACLF 患者 LT 的风险/获益。然而，该评分远非完美，在使用这些工具时，还需要考虑患者的偏好和中心特定因素等其他因素。
