Characteristics, Diagnosis and Prognosis of Acute-on-Chronic Liver Failure in Cirrhosis Associated to Hepatitis B.

Hai Li,Xiong Ma,Geoffrey Dusheiko,Marco Pavesi,Shu-Ting Li,Vicente Arroyo,Jing Hua,Àlex Amorós,Qing Xie,Richard Moreau,Li Sheng,Rajiv Jalan,Feng Xue,Dekai Qiu ,Qian Xin ,Pere Ginés ,Graham R Foster ,Bing Zeng ,Liuying Chen ,Nannan Zhang ,Rajeshwar P Mookerjee

doi:10.1038/srep25487

Abstract

The diagnostic and prognostic criteria of acute-on-chronic liver failure (ACLF) were developed in patients with no Hepatitis B virus (HBV) cirrhosis (CANONIC study). The aims of this study were to evaluate whether the diagnostic (CLIF-C organ failure score; CLIF-C OFs) criteria can be used to classify patients; and the prognostic score (CLIF-C ACLF score) could be used to provide prognostic information in HBV cirrhotic patients with ACLF. 890 HBV associated cirrhotic patients with acute decompensation (AD) were enrolled. Using the CLIF-C OFs, 33.7% (300 patients) were diagnosed as ACLF. ACLF was more common in the younger patients and in those with no previous history of decompensation. The most common organ failures were ‘hepatic’ and ‘coagulation’. As in the CANONIC study, 90-day mortality was extremely low in the non-ACLF patients compared with ACLF patients (4.6% vs 50%, p < 0.0001). ACLF grade and white cell count, were independent predictors of mortality. CLIF-C ACLFs accurately predicted short-term mortality, significantly better than the MELDs and a disease specific score generated for the HBV patients. Current study indicates that ACLF is a clinically and pathophysiology distinct even in HBV patients. Consequently, diagnostic criteria, prognostic scores and probably the management of ACLF should base on similar principles.

Highlights

Acute on chronic liver failure (ACLF) is a dynamic syndrome observed in the hospitalized cirrhotic patients either with or without an identified precipitating factor characterized by hepatic and or extrahepatic organ failures and high mortality[1]
One of the limitations of the chronic liver failure (CLIF) consortium classification is that it has only been validated in cohorts of patients from Europe and the patient populations studied had an extremely low prevalence of Hepatitis B virus (HBV) infection, which is the commonest cause of chronic liver disease in the Eastern Pacific rim
Given that infection with HBV may be associated with disease flares, which can lead to rapid deterioration in liver function despite introduction of effective antiviral therapy, it is unclear whether criteria developed for non-HBV induced acute-on-chronic liver failure (ACLF) can be applied to patients with HBV related ACLF

Summary

Introduction

Acute on chronic liver failure (ACLF) is a dynamic syndrome observed in the hospitalized cirrhotic patients either with or without an identified precipitating factor characterized by hepatic and or extrahepatic organ failures and high mortality[1]. The North American Consortium for the Study of End Stage Liver Disease (NACSELD), made similar observations confirming high mortality rates of patients with organ failures in the hospitalized cirrhotic patients with bacterial infection[6]. A Consensus definition has of necessity been developed under the auspices of the Asia Pacific association for the Study of liver disease for the definition of ACLF, which is based on expert opinion, rather than prospectively validated data. A World Consensus on the definition of ACLF was organized under the auspices of the World Congress of Gastroenterology, which amongst other recommendations concluded that the CLIF criteria should be validated in an Asian population that included patients with HBV infection[9]. In order to achieve these aims, the EASL CLIF Consortium set up collaboration with Ren Ji Hospital, Shanghai, China and all the data were analyzed by the Data Management Centre of the EASL CLIF Consortium in a manner similar to that performed for the CANONIC study[4] to allow direct comparison

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