Prevalence and short-term mortality of acute-on-chronic liver failure: A national cohort study from the USA

Hernáez, Rubén; Kramer, Jennifer R.; Liu, Yan; Tansel, Aylin; Natarajan, Yamini; Hussain, Khozema B.; Ginès, Pere; Solà, Elsa; Moreau, Richard; Gerbes, Alexander L.; El–Serag, Hashem B.; Kanwal, Fasiha

doi:10.1016/j.jhep.2018.12.018

Cited by 113 publications

(107 citation statements)

References 11 publications

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“…Patients with acute decompensation of cirrhosis (AD) or acute‐on‐chronic liver failure (ACLF) have progressive changes in their hemostatic system and are at particular risk for bleeding and thrombotic complications . Patients with ACLF are characterized by development of organ failure and high short‐term mortality . An intense systemic inflammatory response that is often complicated (or precipitated) by infection is one of the hallmarks of ACLF .…”

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confidence: 99%

Mixed Fibrinolytic Phenotypes in Decompensated Cirrhosis and Acute‐on‐Chronic Liver Failure with Hypofibrinolysis in Those With Complications and Poor Survival

et al. 2019

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Background and Aims Patients with liver disease acquire complex changes in their hemostatic system, which results in a fragile rebalanced status. The status of the fibrinolytic system is controversial, as is the role of fibrinolytic dysfunction in bleeding and thrombosis in patients with cirrhosis. Here, we aimed to determine fibrinolytic status and its relationship with outcome in acutely ill patients with cirrhosis. Approach and Results We assessed plasma fibrinolytic potential in a large cohort of patients with acutely decompensated cirrhosis (AD, n = 52) or acute‐on‐chronic liver failure (ACLF, n = 57). Compared with 40 healthy volunteers, median clot lysis times (CLTs) were shorter in patients with AD but comparable to controls in patients with ACLF. However, the variability in CLTs in patients was much larger than in healthy controls, and in both patient groups, a proportion of patients had clearly prolonged or shortened CLTs. The variability in CLTs in patients was not readily explained by variations in plasma levels of key fibrinolytic proteins. However, CLTs were clearly related to clinical characteristics, with longer CLTs in patients with sepsis and patients with any organ failure (as defined by the European Foundation for the Study of Chronic Liver Disease organ failure scores). CLTs were not different between patients that did or did not experience bleeding or a thrombotic event during follow‐up. Baseline CLTs were substantially longer in patients that died within 30 days of admission. Conclusions Our study demonstrates a mixed fibrinolytic phenotype in acutely ill patients with cirrhosis with baseline hypofibrinolysis associated with sepsis, organ failure, and short‐term mortality. These associations may be explained by defective clearance of intraorgan microthrombi that have been proposed to drive organ failure.

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confidence: 99%

Mixed Fibrinolytic Phenotypes in Decompensated Cirrhosis and Acute‐on‐Chronic Liver Failure with Hypofibrinolysis in Those With Complications and Poor Survival

et al. 2019

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“…Secondly, this study may overestimate the survival outcome of both ACLF and decompensated cirrhosis patients, as we only included patients survived over the first 3 months. In a national cohort study from the US, 40% of patients with ACLF died within 3 months 23. Regardless, the research is unique in that the risk for HCC and the long-term survival was analysed in patients who had survived the ACLF episode.…”

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confidence: 99%

Long‐term outcomes of patients with hepatitis B virus‐related acute on chronic liver failure: An observational cohort study

Lin

Zhang

et al. 2019

Liver International

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Background and Aims The long‐term outcomes of patients with hepatitis B virus‐related acute on chronic liver failure (HBV‐ACLF) remain unclear. The main aim of the study was to compare the 5‐year survival rate and incidence rate of hepatocellular carcinoma (HCC) between patients with HBV‐ACLF and HBV‐cirrhosis. Methods Clinical data of patients with ACLF, compensated cirrhosis and decompensated cirrhosis who survived more than 3 months after diagnosis were collected. The survival rate and cumulative incidence of HCC were compared. The Cox regression was used to evaluate risk factors for outcomes. Results A total of 814 patients were included in the analysis, including 122 (14.99%) patients with ACLF, 450 (55.28%) patients with compensated cirrhosis and 242 (29.73%) patients with decompensated cirrhosis. The 5‐year survival rate of patients with ACLF (97.2%) was higher than patients with decompensated cirrhosis (86.0%), but was lower than patients with compensated cirrhosis (99.1%). The 5‐year HCC incidence rate was the highest in the decompensated cirrhosis group (14.6%, P < 0.05), while no statistical differences were found between patients with ACLF (3.5%) and compensated cirrhosis (9.5%). The episode of ACLF did not increase the risk of HCC and the overall survival when compared with patients with cirrhosis. In ACLF subgroup analysis, the age, rather than the presence of cirrhosis, was independently associated with both mortality and incidence of HCC. Conclusions ACLF patients who survived the first 3 months had a better long‐term prognosis than decompensated cirrhosis, while the HCC risk was comparable to compensated cirrhosis. HCC surveillance is strongly recommended for these patients.

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“…Despite only one‐sixth of the hospitalized population with cirrhosis being seen at academic LT centers, LT centers generate the vast majority of the literature advising inpatient cirrhosis management. Similar to this study, an analysis of the Veterans Administration database over a similar timeframe consisted of <10% of patients hospitalized at LT centers, but this population was predominantly composed of male veterans, limiting its external validation . The NACSELD‐ACLF score demonstrates its broadest appeal among patients and providers at non‐LT hospitals.…”

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confidence: 73%

The North American Consortium for the Study of End‐Stage Liver Disease–Acute‐on‐Chronic Liver Failure Score Accurately Predicts Survival: An External Validation Using a National Cohort

et al. 2020

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Acute-on-chronic liver failure (ACLF) carries high short-term mortality. The North American Consortium for the Study of End-Stage Liver Disease (NACSELD)-ACLF score, positive if ≥2 organ failures are present, is a bedside tool that predicts short-term mortality in patients with cirrhosis. However, it was created using major liver referral centers, where a minority of patients with cirrhosis are hospitalized. Therefore, this study used the Nationwide Inpatient Sample, a nationally representative database, from 2005 to 2014 to externally validate the NACSELD-ACLF score in a cohort of patients with decompensated cirrhosis who were identified by a validated algorithm. Organ failures were identified using diagnosis codes. The primary objective was to evaluate the association between the NACSELD-ACLF score and inpatient mortality, whereas secondary objectives compared outcomes depending on presence of infection or hospitalization at a transplant center. Multivariate logistic regression was used to compare outcomes, and area under the curve was calculated. There were 1,523,478 discharges that were included with 106,634 (7.0%) having a positive NACSELD-ACLF score. Patients were a mean 58 years old, and a majority were white men. Infection was present in 33.7% of the sample. Inpatient survival decreased with each organ failure and if infection was present. Patients with the NACSELD-ACLF score had significantly lower inpatient survival on crude (94% versus 48%; P < 0.001) and multivariate analysis (odds ratio [OR], 0.08; 95% confidence interval [CI], 0.07-0.08) and area under the receiver operating characteristic curve 0.77 (95% CI, 0.77-0.78). Liver transplant centers had clinically similar but significantly better survival at each organ failure, in patients with the NACSELD-ACLF score, and on multivariate analysis (OR, 1.17; 95% CI, 1.13-1.22). Using a national cohort, our study validated the NACSELD-ACLF score as an excellent, simple bedside tool to predict short-term survival in patients with decompensated cirrhosis. 26 187-195 2020 AASLD. Liver Transplantation

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Prevalence and short-term mortality of acute-on-chronic liver failure: A national cohort study from the USA

Cited by 113 publications

References 11 publications

Mixed Fibrinolytic Phenotypes in Decompensated Cirrhosis and Acute‐on‐Chronic Liver Failure with Hypofibrinolysis in Those With Complications and Poor Survival

Mixed Fibrinolytic Phenotypes in Decompensated Cirrhosis and Acute‐on‐Chronic Liver Failure with Hypofibrinolysis in Those With Complications and Poor Survival

Long‐term outcomes of patients with hepatitis B virus‐related acute on chronic liver failure: An observational cohort study

The North American Consortium for the Study of End‐Stage Liver Disease–Acute‐on‐Chronic Liver Failure Score Accurately Predicts Survival: An External Validation Using a National Cohort

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