Considerations for Prognosis, Goals of Care, and Specialty Palliative Care for Hospitalized Patients With Acute‐on‐Chronic Liver Failure

Model for end-stage liver disease-sodium underestimates 90-day mortality risk in patients with acute-on-chronic liver failure

“…Similar results were also observed in analyses stratified by ACLF grades in terms of hepatic decompensation or causes of cirrhosis; however, compared to ACLF-1, patients with ACLF-2 and 3 had greater prevalence of bacterial infection (10.5% for ACLF-1 compared to 16.4% and 23.38% for ACLF-2 and 3, respectively) and alcoholism (22.9% for ACLF-1, compared to 33.2% and 36.8 for ACLF-2 and 3, respectively). The median (P25-P75) MELD-Na on admission was 26 (22-30) for ACLF compared to 15 (12)(13)(14)(15)(16)(17)(18)(19)(20) for patients without ACLF; it was 24 (21-27), 27 (23-31), and 32 (26-37) for ACLF-1, 2 and 3 patients, respectively.…”

“…Frequencies and proportions of liver transplant consideration at index admission and 180 days from diagnosis of ACLF, n (%, columns). 9 (2.8) 0 (0.0) 0 (0.0) 0 (0.0) 0 (0.0) [10][11][12][13][14][15][16][17][18][19] 211 (65.5) 9 (3.4) 3 (4.8) 6 (4.4) 0 (0.0) [20][21][22][23][24][25][26][27][28][29] ACLF, acute-on-chronic liver failure; MELD-Na, model for end-stage-liver disease-sodium. considered in calculating MELD-Na.…”

“…Specifically, using NACSELD-ACLF, the 90-day mortality in patients with ACLF was significantly higher than expected based on MELD-Na scores (overall SMR 1.7; 95% CI 1.6-1.7). The disparity was largest for MELD-Na [0-9]: SMR (24.8; 95% CI 9.4-40.2); compared to MELD-Na [10][11][12][13][14][15][16][17][18][19] and [20][21][22][23][24][25][26][27][28][29] which had SMRs of 7.9 (95% CI 7.2-8.5) and 2.1 (95% CI 2.0-2.2), respectively. Limiting our primary cohort to patients with bilirubin > − 5 mg/dl and INR > − 1.5 did not change our inference either.…”

“…4,5 While not all patients with ACLF may be candidates for LT, our data show that an effort should be made to establish protocols on how to assess the critical needs of these patients independently of MELD-Na. 18 Future research should also focus on developing and validating prognostic scores that incorporate dynamic changes in patients clinical course and novel biomarkers to identify the highest risk patients, [19][20][21] as well as the golden window of time 13 when application of liver-directed therapies might improve patient outcomes, treatments and prognosis while they are being evaluated for LT. 22,23 Our work has several limitations. First, we did not capture longitudinal changes of ACLF scores over time, so patients who were ACLF-3 could experience improvement over time.…”

A dynamic prediction model for prognosis of acute-on-chronic liver failure based on the trend of clinical indicators

“…In the future, a definitive stratified analysis of ACLF patients with a single cause, same severity and stage may help to further clarify the role of ALSS interventions on the prognosis. It is well known that ACLF is a dynamic syndrome which is reversible in a considerable proportion of patients, and this feature is closely related to improvement of prognosis, suggesting the importance of sequential dynamic www.nature.com/scientificreports/ assessment 25,26 . Moreau et al 7 reported that when the CLIF-C ACLF score was computed at 48 h, 3-7 days, and 8-15 days after the diagnosis of ACLF, the predictive accuracy of 28-day mortality was significantly better than when the score was calculated at the diagnosis.…”