NACSELD acute‐on‐chronic liver failure (NACSELD‐ACLF) score predicts 30‐day survival in hospitalized patients with cirrhosis

We hypothesize that the prevalence of chronic kidney disease (CKD) among patients with cirrhosis has increased due to the increased prevalence of CKD‐associated comorbidities, such as diabetes. We aimed to assess the characteristics of hospitalized patients with cirrhosis with CKD and its impact on renal and patient outcomes. The North American Consortium for the Study of End‐Stage Liver Disease (NACSELD) prospectively enrolled nonelectively admitted patients with cirrhosis and collected data on demographics, laboratory results, in‐hospital clinical course, and postdischarge 3‐month outcomes. CKD positive (CKD+) patients, defined as having an estimated glomerular filtration rate (eGFR; Modification of Diet in Renal Disease–4 variable formula) of ≤60 mL/minute for >3 months, were compared with chronic kidney disease negative (CKD–) patients for development of organ failures, hospital course, and survival. There were 1099 CKD+ patients (46.8% of 2346 enrolled patients) who had significantly higher serum creatinine (2.21 ± 1.33 versus 0.83 ± 0.21 mg/dL in the CKD– group) on admission, higher prevalence of nonalcoholic steatohepatitis cirrhosis etiology, diabetes, refractory ascites, and hospital admissions in the previous 6 months compared with the CKD– group (all P < 0.001). Propensity matching (n = 922 in each group) by Child‐Pugh scores (9.78 ± 2.05 versus 9.74 ± 2.04, P = 0.70) showed that CKD+ patients had significantly higher rates of superimposed acute kidney injury (AKI; 68% versus 21%; P < 0.001) and eventual need for dialysis (11% versus 2%; P < 0.001) than CKD– patients. CKD+ patients also had more cases of acute‐on‐chronic liver failure as defined by the NACSELD group, which was associated with reduced 30‐ and 90‐day overall survival (P < 0.001 for both). A 10 mL/minute drop in eGFR was associated with a 13.1% increase in the risk of 30‐day mortality. In conclusion, patients with CKD should be treated as a high‐risk group among hospitalized patients with cirrhosis due to their poor survival, and they should be monitored carefully for the development of superimposed AKI.

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“… ‡ ACLF is defined as ≥2 organ failures as per the NACSELD from Bajaj et al (2014) and O’Leary et al (2018). …”

Section: Resultsmentioning

confidence: 99%

Impact of Chronic Kidney Disease on Outcomes in Cirrhosis

Wong

Reddy

O’Leary³

et al. 2019

Liver Transpl

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“…EASL describes them as an acute precipitant among 21% patients with AD and in 30% patients with ACLF . North American Consortium for the Study of Liver Diseases describes them as a precipitant in majority of the patients with ACLF at admission . We have previously shown sepsis or SBP as the commonest acute precipitant in 66% admitted patients with ACLF .…”

Section: Discussionmentioning

confidence: 99%

Prediction of 28‐day mortality in acute decompensation of cirrhosis through the presence of multidrug‐resistant infections at admission

Gupta

Lochan

Verma

et al. 2019

J of Gastro and Hepatol

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Background and Aim The aim of this study is to evaluate the epidemiology and impact of bacterial infections at admission in patients with acute decompensation (AD) of cirrhosis. Methods A cohort with AD of cirrhosis (European Association for the Study of the Liver criteria) admitted at a tertiary center was evaluated between 2013 and 2014 for the presence of bacterial infections at admission. Clinical, demographic, and microbiological data were collected prospectively till death, transplant, or 90 days. Results Of 179 patients with AD, 102 (56.9%) had bacterial infections at admission. The commonest infections were spontaneous bacterial peritonitis (SBP) (n = 65; 63.7%), spontaneous bacteremia (n = 10; 9.8%), pneumonia (n = 9; 8.8%), urinary tract infection (n = 8; 7.8%), spontaneous bacterial empyema (n = 4; 3.9%), and cellulitis (n = 2; 1.9%). The commonest source was community acquired (n = 85; 83.3%). Serum albumin and sodium levels were lower in infected as compared with non‐infected cohort (P = 0.015; for both). Escherichia coli was the commonest organism isolated from SBP (n = 14; 21.5%), urinary tract infection (n = 5; 45.5%), and bacteremia (n = 3; 20%). There was a trend toward higher 28‐day mortality in infected cohort as compared with non‐infected cohort (48 [52.7%] vs 28 [32%]; P = 0.152). Multidrug‐resistant organisms (MDROs) were isolated in 63% of all culture‐positive infections. The presence of MDRO was an independent predictor of 28‐day mortality. Conclusions Infections are the leading reason for the occurrence of AD; SBP is the most common infection, and E. coli is the commonest microorganism based on this single‐center study of Indian patients with AD of cirrhosis. There is a high prevalence of MDROs among culture‐positive infections that independently predict 28‐day mortality in AD of cirrhosis.

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“…Because infections are one of the most common complications leading to ACLF and delisting, it is imperative that clinicians reduce the risk for infectious complications for patients with cirrhosis . Therefore, it is surprising that more than half of all admitted patients were taking a PPI.…”

Section: Discussionmentioning

confidence: 99%

“…With an increased need for LT and the changes in the patient population listed for transplant, we expect more patients to need hospitalization before transplant . In addition, we anticipate ACLF will also continue to increase in incidence before LT. Current data have shown that transplant‐free survival is markedly reduced in patients who develop ACLF, regardless of the definition of ACLF used . This is also applicable to patients listed for LT who have a high mortality before LT once ACLF develops …”

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confidence: 91%

Outcomes After Listing for Liver Transplant in Patients With Acute‐on‐Chronic Liver Failure: The Multicenter North American Consortium for the Study of End‐Stage Liver Disease Experience

et al. 2019

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Acute‐on‐chronic liver failure (ACLF) characterized with ≥2 extrahepatic organ failures in cirrhosis carries a high mortality. Outcomes of patients listed for liver transplantation (LT) after ACLF and after LT are largely unknown. The North American Consortium for the Study of End‐Stage Liver Disease prospectively enrolled 2793 nonelectively hospitalized patients with cirrhosis; 768 were listed for LT. Within 3 months, 265 (35%) received a LT, 395 remained alive without LT, and 108 died/delisted. Compared with nonlisted patients, those listed were younger and more often had ACLF, acute kidney injury, and a higher admission Model for End‐Stage Liver Disease (MELD) score. ACLF was most common in patients who died/delisted, followed by those alive with and without LT respectively, (30%, 22%, and 7%, respectively; P < 0.001). At LT, median MELD was 27.9% and 70% were inpatients; median time from hospitalization to LT was 26 days. Post‐LT survival at 6 months was unchanged between those with and without ACLF (93% each at 6 months). There was no difference in 3‐ and 6‐month mean post‐LT creatinine in those with and without ACLF, despite those with ACLF having a higher mean pre‐LT creatinine and a higher rate of perioperative dialysis (61%). In conclusion, patients with and without ACLF had similar survival after transplant with excellent renal recovery in both groups.

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NACSELD acute‐on‐chronic liver failure (NACSELD‐ACLF) score predicts 30‐day survival in hospitalized patients with cirrhosis

Cited by 213 publications

References 34 publications

Impact of Chronic Kidney Disease on Outcomes in Cirrhosis

Impact of Chronic Kidney Disease on Outcomes in Cirrhosis

Prediction of 28‐day mortality in acute decompensation of cirrhosis through the presence of multidrug‐resistant infections at admission

Outcomes After Listing for Liver Transplant in Patients With Acute‐on‐Chronic Liver Failure: The Multicenter North American Consortium for the Study of End‐Stage Liver Disease Experience

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