Department of Medicine, Division of Liver Diseases, Recanati/Miller Transplantation Institute, Icahn School of Medicine at Mount Sinai, New York, New York, USA.
Department of Medicine, Mount Sinai Morningside and West, New York, New York, USA.
Hepatol Commun. 2024 Aug 19;8(9). doi: 10.1097/HC9.0000000000000514. eCollection 2024 Sep 1.
Severe alcohol-associated hepatitis (AH) that is nonresponsive to corticosteroids is associated with high mortality, particularly with concomitant acute-on-chronic liver failure (ACLF). Most patients will not be candidates for liver transplantation (LT) and their outcomes are largely unknown. Our aim was to determine the outcomes of these declined candidates and to derive practical prediction models for transplant-free survival applicable at the time of the waitlist decision.
We analyzed a database of patients with severe AH who were hospitalized at a LT center from January 2012 to July 2021, using the National Death Index for those lacking follow-up. Clinical variables were analyzed based on the endpoints of mortality at 30, 60, 90, and 180 days. Logistic and Cox regression analyses were used for model derivation.
Over 9.5 years, 206 patients with severe AH were declined for LT, mostly for unfavorable psychosocial profiles, with a mean MELD of 33 (±8), and 61% with ACLF. Over a median follow-up of 521 (17.5-1368) days, 58% (119/206) died at a median of 21 (9-124) days. Of 32 variables, only age added prognostic value to MELD and ACLF grade. CLIF-C ACLF score and 2 new models, MELD-Age and ACLF-Age, had similar predictability (AUROC: 0.73, 0.73, 0.72, respectively), outperforming Lille and Maddrey's (AUROC: 0.63, 0.62). In internal cross-validation, the average AUROC was 0.74. ACLF grade ≥2, MELD score >35, and age >45 years were useful cutoffs for predicting increased 90-day mortality from waitlist decision. Only two patients initially declined for LT for AH subsequently underwent LT (1%).
Patients with severe AH declined for LT have high short-term mortality and rare rates of subsequent LT. Age added to MELD or ACLF grade enhances survival prediction at the time of waitlist decision in patients with severe AH declined for LT.
对皮质类固醇无反应的严重酒精相关性肝炎（AH）与高死亡率相关，特别是伴有慢性肝衰竭急性加重（ACLF）的情况下。大多数患者不符合肝移植（LT）的条件，其预后很大程度上未知。我们的目的是确定这些被拒绝的患者的结局，并得出适用于等待名单决策时的无移植生存的实用预测模型。
我们分析了 2012 年 1 月至 2021 年 7 月在 LT 中心住院的严重 AH 患者的数据库，对于缺乏随访的患者使用国家死亡索引。根据 30、60、90 和 180 天的死亡率终点分析临床变量。逻辑和 Cox 回归分析用于模型推导。
在 9.5 年期间，206 例严重 AH 患者因 LT 被拒绝，主要是由于不利的社会心理特征，平均 MELD 为 33（±8），61%的患者伴有 ACLF。在中位数为 521（17.5-1368）天的中位随访期间，58%（119/206）的患者在中位数为 21（9-124）天内死亡。在 32 个变量中，只有年龄增加了 MELD 和 ACLF 分级的预后价值。CLIF-C ACLF 评分和 2 个新模型（MELD-Age 和 ACLF-Age）具有相似的预测能力（AUROC：0.73、0.73、0.72），优于 Lille 和 Maddrey 的评分（AUROC：0.63、0.62）。内部交叉验证的平均 AUROC 为 0.74。ACLF 分级≥2、MELD 评分>35 和年龄>45 岁是从等待名单决策开始预测 90 天死亡率增加的有用截止值。仅有 2 例最初因 AH 被拒绝接受 LT 的患者随后接受了 LT（1%）。
因严重 AH 被拒绝接受 LT 的患者短期死亡率较高，且很少接受后续 LT。年龄增加到 MELD 或 ACLF 分级可增强因严重 AH 被拒绝接受 LT 的患者等待名单决策时的生存预测。
