Abstract
BackgroundAcute-on-chronic liver failure (ACLF) is a severe complication of cirrhosis and is defined by organ failure and high rates of short-term mortality. Patients with ACLF are managed with multiorgan support in the intensive care unit (ICU). Currently, it is unclear when this supportive care becomes futile, particularly in patients who are not candidates for liver transplant. The aim of this study was to determine whether the currently available prognostic scores can identify patients with ACLF in whom prolonged ICU care is likely to be futile despite maximal treatment efforts.MethodsData of 202 consecutive patients with ACLF admitted to the ICU at the Royal Free Hospital London between 2005 and 2012 were retrospectively analyzed. Prognostic scores for chronic liver diseases, such as Child-Pugh, Model for End-Stage Liver Disease (MELD), European Foundation for the study of chronic liver failure (CLIF-C) organ failure (OF), and CLIF-C ACLF, were calculated 48 hours after ICU admission and correlated with patient outcome after 28 days.ResultsThe CLIF-C ACLF score, compared with all other scores, most accurately predicted 28-day mortality, with an area under the receiver operator characteristic of 0.8 (CLIF-C OF, 0.75; MELD, 0.68; Child-Pugh, 0.66). A CLIF-C ACLF score cutoff ≥ 70 identified patients with a 100% mortality within 28 days. These patients had elevated inflammatory parameters representing a systemic inflammatory response, most often renal failure, compared with patients below this cutoff.ConclusionsPatients with ACLF and high CLIF-C ACLF score (≥ 70) after 48 hours of intensive care may reach a threshold of futility for further ongoing intensive support. The best treatment options in this scenario remain to be determined but may include palliative care.
Highlights
Acute-on-chronic liver failure (ACLF) is a severe complication of cirrhosis and is defined by organ failure and high rates of short-term mortality
We aimed to evaluate the short-term outcome of patients with ACLF and compared the predictive value of the chronic liver failure (CLIF)-C ACLF score against other prognostic scores and clinical variables 48 hours after full intensive care support and regardless of when ACLF was first diagnosed
In relation to deaths within 48 hours, of the 202 patients included in the study, 9 ACLF grade 3 and 6 ACLF grades 1 + 2 patients died just within this time point, albeit that their retrospective ACLF score classifications were based on the last available data points premortem
Summary
Acute-on-chronic liver failure (ACLF) is a severe complication of cirrhosis and is defined by organ failure and high rates of short-term mortality. Patients with ACLF are managed with multiorgan support in the intensive care unit (ICU). It is unclear when this supportive care becomes futile, in patients who are not candidates for liver transplant. Acute-on-chronic liver failure (ACLF) is a syndrome that develops in patients with an acute decompensation of liver cirrhosis and is characterized by development of organ failure and high short-term mortality [1]. Depending on the ACLF grade, 28-day mortality ranges from 23.3% in ACLF grade 1 to 75.5% in ACLF grade 3 [1], and most patients require intensive care and organ support [3, 4]. The 28-day mortality varied from below 20% in CLIF-C ACLF score < 45 to more than 80% in CLIF-C ACLF score ≥ 65 [2]
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