Severe Alcohol‐Associated Hepatitis Is Associated With Worse Survival in Critically Ill Patients With Acute on Chronic Liver Failure

Abstract

Differences in mortality between critically ill patients with severe alcohol‐associated hepatitis (sAH) and acute‐on‐chronic liver failure (ACLF) and non‐sAH ACLF (i.e., ACLF not precipitated by sAH) are unknown. Such differences are important, as they may inform on prognosis and optimal timing of liver transplantation (LT). Thus, we aimed to compare short‐term and longer‐term mortality between patients with sAH ACLF and patients with non‐sAH ACLF who were admitted to the intensive care unit. Patients with ACLF admitted from 2016‐2018 at two tertiary care intensive care units were analyzed. SAH was defined by the National Institute on Alcohol Abuse and Alcoholism’s Alcoholic Hepatitis Consortium and Model for End‐Stage Liver Disease score >20. Mortality without LT was compared between sAH ACLF and non‐sAH ACLF using Fine and Gray’s competing‐risks regression. A total of 463 patients with ACLF (18% sAH and 82% non‐sAH) were included. Compared to patients with non‐sAH ACLF, patients with sAH ACLF were younger (49 vs. 56 years; P < 0.001) and had higher admission Model for End‐Stage Liver Disease (MELD) (35 vs. 25; P < 0.001) and Chronic Liver Failure Consortium (CLIF‐C) scores (61 vs. 57; P = 0.002). There were no significant differences between the two groups for vasopressor, mechanical ventilation, and hemodialysis use. The cumulative incidence of death was significantly higher in patients with sAH ACLF compared to patients with non‐sAH ACLF: 30‐day 74.7% versus 45.3%; 90‐day 81.9% versus 57.4%; 180‐day 83.2% versus 63.0% (unadjusted subdistribution hazard ratio [sHR] 1.88 [95% confidence interval (CI) 1.44‐2.46]; P < 0.001). After adjusting for CLIF‐C score and infection in a multivariable competing‐risk model, patients with sAH ACLF had significantly higher risk of death (sHR 1.57 [95% CI 1.20‐2.06]; P = 0.001) compared to patients with non‐sAH ACLF. Conclusion: Critically ill patients with sAH ACLF have worse mortality compared to patients with non‐sAH ACLF. These data may inform prognosis in patients with sAH and ACLF, and early LT referral in potentially eligible patients.

The prognostic impact of acute kidney injury recovery patterns in critically ill patients with cirrhosis

“…Potential strategies to facilitate AKI recovery include prompt recognition and treatment of infection,22 dexmedetomidine sedation,23,24 avoidance of contrast medium,25 and maintaining a MAP >65 mm Hg 26. Other independent predictors of mortality that were found in our study included the presence of severe AAH, CLIF-C score, and ascites which are in line with previous studies 27–30…”

“…[26] Other independent predictors of mortality that were found in our study included the presence of severe AAH, CLIF-C score, and ascites which are in line with previous studies. [27][28][29][30] In non-ICU patients with cirrhosis and AKI, hypovolemic AKI, and to a lesser extent hepatorenal syndrome and acute tubular necrosis, is the most common phenotype. [3,5,6,31] In our study, hypovolemic (56%) and acute tubular necrosis (41%) were the most common phenotypes, whereas hepatorenal syndrome was uncommon (1%).…”

Herpes Simplex Virus Bronchopneumonitis in Critically Ill Patients with Acute on Chronic Liver Failure: A Retrospective Analysis

“…One factor is the fact that our study only included the most severely ill patients with ACLF, multiple organ dysfunctions or failures, and generally very high mortality. Overall mortality of critically ill patients with ACLF in the literature varies from 32% to 45.3% [ 10 , 12 ], while mortality in our cohort including all 232 patients with and without mechanical ventilation was 56.9%. As we only included patients with respiratory failure and mechanical ventilation, mortality was even higher (76%, 104 out of 136 patients).…”

“…ACLF is a clinical syndrome defined by acute deterioration of a chronic liver disease with the combination of acute decompensation and multiorgan failure [10,11]. Critically ill patients with ACLF are known to have a substantial mortality rate, varying from 32% to Viruses 2024, 16, 419 2 of 10 45.3% [10,12]. The increased vulnerability of patients with ACLF has different causes.…”

Alcohol use disorder in the intensive care unit a highly morbid condition, but chemical dependency discussion improves outcomes

“…Improvements in supportive care can resolve the acute illness, but long-term treatments for liver failure are still lacking. Liver dysfunction has been associated with impaired immune functioning, higher risk of bleeding, increased rates and worse outcomes in acute respiratory distress syndrome, and changes in metabolism and nutrition, which may account for the increased risk of mortality in these patients during and after acute illness [ 29 - 35 ].…”