The Prediction of In‐Hospital Mortality in Decompensated Cirrhosis with Acute‐on‐Chronic Liver Failure

Abstract

Acute‐on‐chronic liver failure (ACLF) is a condition in cirrhosis associated with organ failure (OF) and high short‐term mortality. Both the European Association for the Study of the Liver‐Chronic Liver Failure (EASL‐CLIF) and North American Consortium for the Study of End‐Stage Liver Disease (NACSELD) ACLF definitions have been shown to predict ACLF prognosis. The aim of this study was to compare the ability of the EASL‐CLIF versus NACSELD systems over baseline clinical and laboratory parameters in the prediction of in‐hospital mortality in admitted patients with decompensated cirrhosis. Five NACSELD centers prospectively collected data to calculate EASL‐CLIF and NACSELD‐ACLF scores for admitted patients with cirrhosis who were followed for the development of OF, hospital course, and survival. Both the number of OFs and the ACLF grade or presence were used to determine the impact of NACSELD versus EASL‐CLIF definitions of ACLF above baseline parameters on in‐hospital mortality. A total of 1031 patients with decompensated cirrhosis (age, 57 ± 11 years; male, 66%; Child‐Pugh‐Turcotte score, 10 ± 2; Model for End‐Stage Liver Disease [MELD] score, 20 ± 8) were enrolled. Renal failure prevalence (28% versus 9%, P < 0.001) was more common using the EASL‐CLIF versus NACSELD definition, but the prevalence rates for brain, circulatory, and respiratory failures were similar. Baseline parameters including age, white cell count on admission, and MELD score reasonably predicted in‐hospital mortality (area under the curve, 0.76). The addition of number of OFs according to either system did not improve the predictive power of the baseline parameters for in‐hospital mortality, but the presence of NACSELD‐ACLF did. However, neither system was better than baseline parameters in the prediction of 30‐ or 90‐day outcomes. The presence of NACSELD‐ACLF is equally effective as the EASL‐CLIF ACLF grade, and better than baseline parameters in the prediction of in‐hospital mortality in patients with cirrhosis, but not superior in the prediction of longer‐term 30‐ or 90‐day outcomes.

Acute-on-Chronic Liver Failure

“…In this case, the situation was even more challenging because this was a new diagnosis of cirrhosis and the patient himself was obtunded. The ICU, hepatology team, and family would benefit from guidance from the palliative care service if available, especially using the NACSELD-ACLF score, which is associated with futility (16–18). This is because liver transplant candidacy depends on multiple factors.…”

“…The ICU, hepatology team, and family would benefit from guidance from the palliative care service if available, especially using the NACSELD-ACLF score, which is associated with futility (16)(17)(18). This is because liver transplant candidacy depends on multiple factors.…”

Proposing a Framework to Assess the Methodological Quality of Prognostic Models

“…Furthermore, to be categorized as ACLF, patients need to have at least 2 EASL‐CLIF OFs. Despite the assertion that “restricting the analysis to only include patients with ≥2 OFs would be against the spirit of the EASL‐CLIF consortium,” ( 2 ) methodologically speaking it would be ideal if the authors provided a secondary analysis to have a head‐to‐head comparison of participants who only had the same OFs, excluding everyone else.…”

“…Wong et al led an analysis of 1031 patients from the North American Consortium for the Study of End‐Stage Liver Disease (NACSELD) and compared 2 different syndrome definitions of ACLF to predict in‐hospital mortality. ( 2 ) Wong et al used the European Association for the Study of Liver Consortium of Liver Failure (EASL‐CLIF), which has 6 organ failure (OF) components, ( 3 ) versus the NACSELD with 4 OF components. ( 4 ) Using the areas under the receiver operating characteristic curve (AUROCs) derived from multivariate logistic regressions, they concluded that either the EASL‐CLIF or NACSELD criteria had a similar discriminatory ability to predict in‐patient hospital mortality compared with a model with age, white blood cell count, and Model for End‐Stage Liver Disease (MELD).…”

Acute-On-Chronic Liver Failure-Outcome and Its Predictors in A Tertiary Care Hospital

“…1 Asian Pacific Association for Study of Liver Diseases (APASL) provided the first consensus, 2 on ACLF in 2009 and later on modified the definition in 2014. In the study by APASL, patients with already decompensated cirrhosis who deteriorated due to acute insult were excluded but other organizations e.g., European Association for Study of Liver Diseases (EASL), 3 and North American Consortium for Study of End-stage Liver Disease (NACSELD) 4 included such patients in their definitions of ACLF.…”