Complications constitute a major risk factor for mortality in hepatitis B virus-related acute-on-chronic liver failure patients: a multi-national study from the Asia-Pacific region

Association Between Artificial Liver Support System and Prognosis in Hepatitis B Virus-Related Acute-on-Chronic Liver Failure

Objective

The artificial liver support system (ALSS) has been recruited as an available method for patients with acute-on-chronic liver failure (ACLF), but its impact on the outcome of ACLF remains controversial. This study aimed to investigate the association between ALSS treatment and short-term prognosis of hepatitis B-related ACLF (HBV-ACLF).

Methods

This was a retrospective observational cohort study, and data were obtained from the Center of Infectious Diseases, West China Hospital of Sichuan University, between Mar 2015 and December 2021. The primary outcome was 28-day transplant-free mortality and the secondary outcomes were 60- and 90-day transplant-free mortality. Patients were divided into standard medical therapy (SMT) and ALSS groups. Kaplan-Meier survival analysis curves show the 28-day, 60-day and 90-day transplant-free mortality. Based on the feature selection result of univariate logistic, univariate Cox and Boruta algorithm, the univariate and multivariate logistic and COX regression models were used to investigate the association of ALSS with 28-day, 60-day and 90-day outcomes in patients with HBV-ACLF. Subgroup analyses were conducted to test the robustness of the results.

Results

A total of 589 hBV-ACLF patients were enrolled in this study (median age, 48.00 years [IQR,44.00-55.00 years]; 70 [11.9%] female). The 28-day, 60-day and 90-day transplant-free mortality rates were 25.6%, 35.8% and 38.9%, respectively. In the univariate and Kaplan-Meier survival analysis, ALSS could significantly reduce 28-day, 60-day and 90-day transplant-free mortality compared to SMT. Furthermore, an in-depth analysis of our study revealed that the therapeutic benefits of the ALSS were observed exclusively within the end-stage (PT-INR ≥ 2.5) subgroup of HBV-ACLF patients.

Conclusion

Compared to SMT, ALSS demonstrated efficacy primarily in enhancing the short- term prognosis of end-stage HBV-ACLF patients, rather than across the entire spectrum of HBV-ACLF patients.

The dual role of regulatory T cells in hepatitis B virus infection and related hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a major contributor to cancer-related deaths worldwide. Hepatitis B virus (HBV) infection is a major etiologic factor leading to HCC. While there have been significant advancements in controlling HBV replication, achieving a complete cure for HBV-related HCC (HBV-HCC) remains an intricate challenge. HBV persistence is attributed to a myriad of mechanisms, encompassing both innate and adaptive immune responses. Regulatory T cells (Tregs) are pivotal in upholding immune tolerance and modulating excessive immune activation. During HBV infection, Tregs mediate specific T cell suppression, thereby contributing to both persistent infection and the mitigation of liver inflammatory responses. Studies have demonstrated an augmented expression of circulating and intrahepatic Tregs in HBV-HCC, which correlates with impaired CD8+ T cell function. Consequently, Tregs play a dual role in the context of HBV infection and the progression of HBV-HCC. In this comprehensive review, we discuss pertinent studies concerning Tregs in HBV infection, HBV-related cirrhosis and HCC. Furthermore, we summarize Treg responses to antiviral therapy and provide Treg-targeted therapies specific to HBV and HCC.

Mixed mode of artificial liver support in patients with acute-on-chronic liver failure: a retrospective cohort study

BACKGROUND AND AIMS

Different modes of artificial liver support (ALS) therapy can improve the survival of patients with acute-on-chronic liver failure (ACLF). This study aimed to compare the effects of mixed using different modes of ALS (MALS) and single using one mode of ALS (SALS) on 28- and 90-day survival rates of ACLF.

METHODS

Clinical data and survival times of patients with ACLF treated for ALS between January 1, 2018 and December 30, 2021 were retrospectively collected. Cox regression analysis was performed to identify risk factors of 28- and 90-day mortalities.

RESULTS

Of the 462 eligible ACLF patients, 388 belonged to the SALS group (76.3% male, 74.2% cirrhosis) and 74 to the MALS group (86.5% male, 71.6% cirrhosis). Comparison of 28-day and 90-day crude mortality between the SALS and MALS groups showed no significant differences (28-day: 20.4% vs. 14.9%, p = 0.27; 90-day: 44.6% vs. 52.7%, p = 0.20). After adjusting for confounders, the 28-day mortality (adjusted hazard ratio [aHR]: 0.32, 95% confidence interval [CI] 0.16-0.65) and 90-day mortality (aHR: 0.65, 95% CI 0.44-0.95) in the MALS group were significantly lower than those in the SALS group. These associations were consistently observed across pre-specified subgroups according to age, sex, etiology, and Child-Pugh grade. However, positive interactions between MALS and 90-day mortality were found between MALS and 90-day mortality in those with MELD score ≥ 22 and international normalized ratio ≥ 1.9 (p for interaction < 0.05).

CONCLUSION

MALS therapy significantly decreased 28- and 90-day mortalities of ACLF than SALS did, especially in advanced stages.

To TIPS or Not to TIPS in High Risk of Variceal Rebleeding and Acute-on-Chronic Liver Failure

Variceal bleeding is a consequence of severe portal hypertension in patients with liver cirrhosis. Although the rate of bleeding has decreased over time, variceal bleeding in the presence of acute-on-chronic liver failure (ACLF) carries a high risk of treatment failure and short-term mortality. Treatment and/or removal of precipitating events (mainly bacterial infection and alcoholic hepatitis) and decrease of portal pressure may improve outcome of patients with acute decompensation or ACLF. Transjugular intrahepatic portosystemic shunts (TIPSs), especially in the preemptive situation, have been found to efficiently control bleeding, prevent rebleeding, and reduce short-term mortality. Therefore, TIPS placement should be considered as an option in the management of ACLF patients with variceal bleeding.

Impact of cirrhosis-related complications on posttransplant survival in patients with acute-on-chronic liver failure

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a life-threatening syndrome defined as acute decompensation in patients with chronic liver disease. Liver transplantation (LT) is the most effective treatment. We aimed to assess the impact of cirrhosis-related complications pre-LT on the posttransplant prognosis of patients with ACLF.

METHODS

This was an observational cohort study conducted between January 2018 and December 2020. Clinical characteristics, cirrhosis-related complications at LT and patient survival post-LT were collected. All liver recipients with ACLF were followed for 1 year post-LT.

RESULTS

A total of 212 LT recipients with ACLF were enrolled, including 75 (35.4%) patients with ACLF-1, 64 (30.2%) with ACLF-2, and 73 (34.4%) with ACLF-3. The median waiting time for LT was 11 (4-24) days. The most prevalent cirrhosis-related complication was ascites (78.8%), followed by hepatic encephalopathy (57.1%), bacterial infections (48.1%), hepatorenal syndrome (22.2%) and gastrointestinal bleeding (11.3%). Survival analyses showed that patients with complications at LT had a significantly lower survival probability at both 3 months and 1 year after LT than those without complications (all P < 0.05). A simplified model was developed by assigning one point to each complication: transplantation for ACLF with cirrhosis-related complication (TACC) model. Risk stratification of TACC model identified 3 strata (≥ 4, = 3, and ≤ 2) with high, median and low risk of death after LT (P < 0.001). Moreover, the TACC model showed a comparable ability for predicting the outcome post-LT to the other four prognostic models (chronic liver failure-consortium ACLF score, Chinese Group on the Study of Severe Hepatitis B-ACLF score, model for end-stage liver disease score and Child-Turcotte-Pugh score).

CONCLUSIONS

The presence of cirrhosis-related complications pre-LT increases the risk of death post-LT in patients with ACLF. The TACC model based on the number of cirrhosis-related complications pre-LT could stratify posttransplant survival, which might help to determine transplant timing for ACLF.

Genetic landscape and immune mechanism of monocytes associated with the progression of acute-on-chronic liver failure

OBJECTIVE

Acute-on-chronic liver failure (ACLF) has a high prevalence and short-term mortality. Monocytes play an important role in the development of ACLF. However, the monocyte subpopulations with unique features and functions in ACLF and associated with disease progression remain poorly understood. We investigated the specific monocyte subpopulations associated with ACLF progression and their roles in inflammatory responses using the single-cell RNA sequencing (scRNA-seq).

METHODS

We performed scRNA-seq on 17,310 circulating monocytes from healthy controls and ACLF patients and genetically defined their subpopulations to characterize specific monocyte subpopulations associated with ACLF progression.

RESULTS

Five monocyte subpopulations were obtained, including pro-inflammatory monocytes, CD16 monocytes, HLA monocytes, megakaryocyte-like monocytes, and NK-like monocytes. Comparisons of the monocytes between ACLF patients and healthy controls showed that the pro-inflammatory monocytes had the most significant gene changes, among which the expressions of genes related to inflammatory responses and cell metabolism were significantly increased while the genes related to cell cycle progression were significantly decreased. Furthermore, compared with the ACLF survival group, the ACLF death group had significantly higher expressions of pro-inflammatory cytokines (e.g., IL-6) and their receptors, chemokines (e.g., CCL4 and CCL5), and inflammation-inducing factors (e.g., HES4). Additionally, validation using scRNA-seq and flow cytometry revealed the presence of a cell type-specific transcriptional signature of pro-inflammatory monocytes THBS1, whose production might reflect the disease progression and poor prognosis.

CONCLUSIONS

We present the accurate classification, molecular markers, and signaling pathways of monocytes associated with ACLF progression. Therapies targeting pro-inflammatory monocytes may be a promising approach for blocking ACLF progression.

Research progress on short-term prognosis of acute-on-chronic liver failure

INTRODUCTION

Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized as a severe condition with rapid progression, poor therapeutic response and poor prognosis. Early and timely evaluation of the prognosis is helpful for providing appropriate clinical intervention and prolonging patient survival.

AREAS COVERED

Currently, there are no specific dynamic and comprehensive approaches to assess the prognosis of patients with ACLF. This article reviews the progress in evaluating the short-term prognosis of ACLF to provide future directions for more dynamic prospective large-scale multicenter studies and a basis for individualized and precise treatment for ACLF patients. We searched PubMed and Web of Science with the term 'acute on chronic liver failure' and 'prognosis.' There was no date or language restriction, and our final search was on 26 October 2022.

EXPERT OPINION

ACLF is a dynamic process, and the best prognostic marker is the clinical evolution of organ failure over time. New prognostic markers are developing not only in the fields of genetics and histology but also toward diversification combined with imaging. Determining which patients will benefit from continued advanced life support is a formidable challenge, and accurate short-term prognostic assessments of ACLF are a good approach to addressing this issue.

Prognosis prediction performs better in patients with non-cirrhosis hepatitis B virus-related acute-on-chronic liver failure than those with cirrhosis

Background

The accurate prediction of the outcome of hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is impeded by population heterogeneity. The study aimed to assess the impact of underlying cirrhosis on the performance of clinical prediction models (CPMs).

Methods

Using data from two multicenter, prospective cohorts of patients with HBV-ACLF, the discrimination, calibration, and clinical benefit were assessed for CPMs predicting 28-day and 90-day outcomes in patients with cirrhosis and those without, respectively.

Results

A total of 919 patients with HBV-ACLF were identified by Chinese Group on the Study of Severe Hepatitis B (COSSH) criteria, including 675 with cirrhosis and 244 without. COSSH-ACLF IIs, COSSH-ACLFs, Chronic Liver Failure-Consortium Acute-on-Chronic Liver Failure score (CLIF-C ACLFs), Tongji Prognostic Predictor Model score (TPPMs), Model for End-Stage Liver Disease score (MELDs), and MELD-Sodium score (MELD-Nas) were all strong predictors of short-term mortality in patients with HBV-ACLF. In contrast to a high model discriminative capacity in ACLF without cirrhosis, each prognostic model represents a marked decline of C-index, net reclassification index (NRI), and integrated discrimination improvement (IDI) in predicting either 28-day or 90-day prognosis of patients with cirrhosis. The hazard analysis identified largely overlapping risk factors of poor outcomes in both subgroups, while serum bilirubin was specifically associated with short-term mortality in patients with cirrhosis and blood urea nitrogen in patients without cirrhosis. A subgroup analysis in patients with cirrhosis showed a decline of discrimination of CPMS in those with ascites or infections compared to that in those without.

Conclusion

Predicting the short-term outcome of HBV-ACLF by CPMs is optimal in patients without cirrhosis but limited in those with cirrhosis, at least partially due to the complicated ascites or infections.

Design for a Multicentre Prospective Cohort for the Assessment of Platelet Function in Patients with Hepatitis-B-Virus-Related Acute-on-Chronic Liver Failure

Background

Acute-on-chronic liver failure (ACLF) has high short-term mortality and lacks sufficient medical therapy. Available algorithms are unable to precisely predict short-term outcomes or safely stratify patients with ACLF as emergent liver transplantation candidates. Therefore, a personalized prognostic tool is urgently needed.

Purpose

Platelet function and its clinical significance in ACLF patients with chronic hepatitis B virus (HBV) infection have not been investigated. This study aimed to assess changes in platelet function using thromboelastography (TEG) and platelet mapping (TEG-PM) in HBV-related ACLF patients.

Methods

Chronic liver disease patients with acute decompensation or acute hepatic injury were recruited. The derivation cohort enrolled HBV-related patients at Nanfang Hospital. HBV-related and non-HBV-related patients were both enrolled in internal and external validation cohorts at seven university hospitals. TEG and TEG-PM were performed at baseline in the derivation cohort and baseline, day 7, and day 14 in the validation cohorts. The primary outcome was all-cause 28-day mortality. Status check and new-onset complications were recorded during the 3-month follow-up, but status check will extend to 5 years.

Conclusion and Future Plans

In this study, 586 participants were enrolled, including 100 in derivation cohort, 133 in internal validation cohort, and 353 in external validation cohort. Biomaterials, including plasma, serum, urine, and some explanted liver tissues, were collected from these patients. A 3-month follow-up with survival status was completed. The baseline characteristics indicated that 51% of the patients had adenosine diphosphate (ADP)-hyporesponsive circulating platelets. The prognostic potential of platelet function will be explored in the derivation cohort (HBV-related ACLF patients) and further substantiated in the validation cohorts (HBV-related and non-HBV-related ACLF patients). Biosamples are currently used to explore the underlying mechanisms related to ADP-hyporesponsive platelets. The ongoing proteomic and metabolic analyses will provide new insights into the pathogenesis of extrahepatic organ failures in ACLF patients.

Liver Transplantation in Acute-on-Chronic Liver Failure: Excellent Outcome and Difficult Posttransplant Course

Background

Acute-on-chronic liver failure (ACLF) patients have high mortality in a short period of time. This study aimed to compare the prognosis of transplanted ACLF patients to that of nontransplanted ACLF patients and decompensated cirrhosis recipients.

Methods

Clinical data of 29 transplanted ACLF patients, 312 nontransplanted ACLF patients, and 60 transplanted decompensated cirrhosis patients were retrospectively collected. Propensity score matching (PSM) analysis was used to match patients between different groups.

Results

After PSM, the 90-day and 1-year survival of transplanted ACLF patients was significantly longer than that of nontransplant controls. Although the 90-day survival and 1-year survival of ACLF recipients was similar to that of decompensated cirrhosis controls, ACLF recipients were found to have longer mechanical ventilation, longer intensive care unit (ICU) stay, longer hospital stay, higher incidence of tracheotomy, higher expense, and higher morbidity of complication than matched decompensated cirrhosis controls. The 90-day and 1-year survival of transplanted ACLF grade 2–3 patients was also significantly longer than that of nontransplanted controls.

Conclusions

Liver transplantation can strongly improve the prognosis of ACLF patients. Despite having more burdens (including longer mechanical ventilation, longer ICU stay, higher incidence of tracheotomy, longer hospital stay, higher hospitalization expense, and higher complication morbidity), ACLF recipients can obtain similar short-term and long-term survival to decompensated cirrhosis recipients. For severe ACLF patients, liver transplantation can also significantly improve their short-term and long-term survival.

Definition and classification of acute-on-chronic liver diseases

Patients with chronic liver diseases (CLDs) develop acute liver injury and/or acute decompensation under the attack of various precipitants and present with significantly elevated alanine aminotransferase and/or total bilirubin levels, liver failure, or acute decompensation of liver cirrhosis, which is called acute-on-CLD (AoCLD). AoCLD accounts for the majority of patients hospitalized in the Department of Hepatology or Infectious Diseases. AoCLD is complicated by various clinical types, the severity of the disease, and may pose a high risk of death. To date, the definition of AoCLD is still vague, and a consensus concept of the clinical classification is lacking. This review aimed to define the concept and clinical types of AoCLD based on related studies and the literature.

Animal models applied to acute-on-chronic liver failure: Are new models required to understand the human condition?

The liver is a multifaceted organ; its location and detoxifying function expose this organ to countless injuries. Acute-on-chronic failure liver (ACLF) is a severe syndrome that affects the liver due to acute decompensation in patients with chronic liver disease. An infection environment, ascites, increased liver enzymes and prothrombin time, encephalopathy and fast-evolving multiorgan failure, leading to death, usually accompany this. The pathophysiology remains poorly understand. In this context, animal models become a very useful tool in this regard, as understanding; the disease may be helpful in developing novel therapeutic methodologies for ACLF. However, although animal models display several similarities to the human condition, they do not represent all ACLF manifestations, resulting in significant challenges. An initial liver cirrhosis framework followed by the induction of an acute decompensation by administering lipopolysaccharide and D-GaIN, potentiating liver damage supports the methodologies applied to induce experimental ACLF. The entire methodology has been described mostly for rats. Nevertheless, a quick PubMed database search indicates about 30 studies concerning ACFL models and over 1000 regarding acute liver failure models. These findings demonstrate the clear need to establish easily reproducible ACFL models to elucidate questions about this quickly established and often fatal syndrome.

Animal models applied to acute-on-chronic liver failure: Are new models required to understand the human condition?

The liver is a multifaceted organ; its location and detoxifying function expose this organ to countless injuries. Acute-on-chronic failure liver (ACLF) is a severe syndrome that affects the liver due to acute decompensation in patients with chronic liver disease. An infection environment, ascites, increased liver enzymes and prothrombin time, encephalopathy and fast-evolving multiorgan failure, leading to death, usually accompany this. The pathophysiology remains poorly understand. In this context, animal models become a very useful tool in this regard, as understanding; the disease may be helpful in developing novel therapeutic methodologies for ACLF. However, although animal models display several similarities to the human condition, they do not represent all ACLF manifestations, resulting in significant challenges. An initial liver cirrhosis framework followed by the induction of an acute decompensation by administering lipopolysaccharide and D-GaIN, potentiating liver damage supports the methodologies applied to induce experimental ACLF. The entire methodology has been described mostly for rats. Nevertheless, a quick PubMed database search indicates about 30 studies concerning ACFL models and over 1000 regarding acute liver failure models. These findings demonstrate the clear need to establish easily reproducible ACFL models to elucidate questions about this quickly established and often fatal syndrome.

Establishment and validation of a prognostic model for hepatitis B virus‑related acute-on-chronic liver failure patients with bacterial infection

BACKGROUND

Bacterial infection is one of the most frequent complications in acute-on-chronic liver failure (ACLF), which leads to high mortality. However, a specific prognostic model for ACLF patients with bacterial infection has not been well established.

AIM

To establish and validate a nomogram for predicting 30-day mortality of hepatitis B virus-related ACLF (HBV-ACLF) patients with bacterial infection.

METHODS

A total of 513 ACLF patients for HBV reactivation were enrolled in the prospective cohort, and 224 patients with bacterial infection were for derivation. Independent predictors were identified using multivariate logistic model and then assembled into a nomogram to predict 30-day mortality. The performance of the nomogram was assessed based on its calibration, discrimination and clinical utility in a retrospective cohort of 192 HBV-ACLF patients with bacterial infection.

RESULTS

Age, total bilirubin, lactate dehydrogenase, international normalized ratio and soluble interleukin-2 receptor were shown to be independent risk factors for 30-day mortality of HBV-ACLF patients with bacterial infection and the nomogram was constructed. The nomogram showed a good calibration and discrimination in the derivation cohort, with an area under the receiver operating characteristic curve (AUC) of 0.883. Application of the nomogram in the validation cohort also showed a good calibration and discrimination, with the AUC of 0.852. Decision curve analysis confirmed the clinical utility of the nomogram.

CONCLUSION

The nomogram was established and validated for predicting 30-day mortality of HBV-ACLF patients with bacterial infection, which may facilitate optimal therapeutic strategies to improve the prognosis of these patients.

HBV-related acute-on-chronic liver failure with underlying chronic hepatitis has superior survival compared to cirrhosis

BACKGROUND

Acute-on-chronic liver failure (ACLF) is divided into three types according to the underlying liver disease: non-cirrhosis (type A), compensated cirrhosis (type B) and decompensated cirrhosis (type C). However, whether the underlying chronic liver diseases impact the ACLF prognosis is not clear. The present study aimed to compare the characteristics and outcomes of type A and type B hepatitis B virus (HBV)-ACLF patients.

METHODS

According to the European Association for the Study of Liver-Chronic Liver Failure (EASL-CLIF) diagnostic criteria, 86 type A HBV-ACLF and 71 type B HBV-ACLF were prospectively enrolled. The demography and laboratory data, organ failures, ACLF grades and prognosis were evaluated. Univariate and multivariate Cox regression analyses were performed to analyze the prognostic factors.

RESULTS

The 28-day and 90-day mortality rates of type A and type B ACLF were 20.9 vs. 60.6% and 34.9 vs. 73.2%, respectively (both P < 0.001). Patients with type A ACLF were younger, had higher viral load and higher levels of alanine aminotransferase and aspartate aminotransferase, platelet count, serum albumin and sodium, international normalized ratio and alpha-fetoprotein, lower rate of ascites, lower Child-Pugh scores and CLIF sequential organ failure assessment scores, higher rate of coagulation failure. Type B ACLF had more renal and cerebral failure. Cirrhosis was one of the independent prognostic factors [hazard ratio, 2.4 (95% CI, 1.451-3.818) P < 0.001].

CONCLUSION

ACLF developing on noncirrhotic chronic hepatitis B had more serious liver inflammation but fewer extrahepatic organ failures and better outcome than ACLF developing from compensated HBV cirrhosis.

Cortisol in Peripheral Blood Predicts the Severity and Prognosis in Patients with Liver Failure at 90 Days

Objective

To investigate the cortisol level in peripheral blood in evaluating the severity and prognosis of patients with liver failure.

Methods

A total of 211 inpatients with liver failure were enrolled in Beijing You ‘an Hospital affiliated with Capital Medical University, from September 2018 to January 2020. They were divided into three groups according to the severity of liver failure: early-stage liver failure, medium-stage liver failure and end-stage liver failure. In all patients, peripheral venous blood was gathered to detect the level of peripheral cortisol and related biochemical indexes. Logistic regression was used to screen the risk factors affecting the prognosis of patients at 90 days. A receiver operating curve (ROC) was used to reflect the value of cortisol on the prognosis of patients at 90 days. A model for end-stage liver disease (MELD) was accessed.

Results

Among these 211 patients with liver failure, aged from 19 to 70 years, the average level of cortisol was 351.26 ± 129.78 nmol/L for 101 cases with early-stage liver failure, 281.05 ± 81.31 nmol/L for 58 cases with medium-stage liver failure, and 189.21 ± 89.27 nmol/L for 52 cases with end-stage liver failure (P < 0.05). The level of cortisol in the survival group and the non-survival group was 339.26 ± 121.19 nmol/L and 192.71 ± 67.23 nmol/L, respectively (P < 0.05). The results of logistics regression analysis showed that the odds ratio (OR) and 95% confidence intervals (CI) of cortisol were 1.025 and 1.013–1.038 nmol/L (P < 0.05). MELD results showed that patients with higher MELD scores had lower cortisol content.

Conclusion

The level of cortisol is correlated with the severity of liver failure and decreases with the aggravation of liver failure, suggesting that the level of cortisol could be used as one of the indicators to evaluate the prognosis in patients with liver failure at 90 days.

Clinical Course and Outcome Patterns of Acute-on-chronic Liver Failure: A Multicenter Retrospective Cohort Study

BACKGROUND AND AIMS

Acute-on-chronic liver failure (ACLF) is acute decompensation of liver function in the setting of chronic liver disease, and characterized by high short-term mortality. In this study, we sought to investigate the clinical course of patients at specific time points, and to propose dynamic prognostic criteria.

METHODS

We assessed the clinical course of 453 patients with ACLF during a 12-week follow-up period in this retrospective multicenter study. The clinical course of patients was defined as disease recovery, improvement, worsening or steady patterns based on the variation tendency in prothrombin activity (PTA) and total bilirubin (TB) at different time points.

RESULTS

Resolution of PTA was observed in 231 patients (51%) at 12 weeks after the diagnosis of ACLF. Among the remaining patients, 66 (14.6%) showed improvement and 156 (34.4%) showed a steady or worsening course. In patients with resolved PTA, the clinical course of TB exhibited resolved pattern in 95.2%, improved in 3.9%, and steady or worse in 0.8%. Correspondingly, in patients with improved PTA, these values for TB were 28.8%, 27.3%, and 43.9%, respectively. In patients with steady or worsening PTA, these values for TB were 5.7%, 32.3%, and 65.6%, respectively. Dynamic prognostic criteria were developed by combining the clinical course of PTA/TB and the clinical outcomes at 4 and 12 weeks after diagnosis in ACLF patients.

CONCLUSIONS

We propose the following dynamic prognostic criteria: rapid progression, slow progression, rapid recovery, slow recovery, and slow persistence, which lay the foundation for precise prediction of prognosis and the improvement of ACLF therapy.

Acute-on-Chronic Liver Failure in Cirrhosis

Acute-on-chronic liver failure (ACLF) is a syndrome that develops in patients with acutely decompensated chronic liver disease. It is characterised by high 28-day mortality, the presence of one or more organ failures (OFs) and a variable but severe grade of systemic inflammation. Despite the peculiarity of each one, every definition proposed for ACLF recognizes it as a proper clinical entity. In this paper, we provide an overview of the diagnostic criteria proposed by the different scientific societies and the clinical characteristics of the syndrome. Established and experimental treatments are also described. Among the former, the most relevant are directed to support organ failures, treat precipitating factors and carry out early assessment for liver transplantation (LT). Further studies are needed to better clarify pathophysiology of the syndrome and discover new therapies.

Proton Pump Inhibitor Therapy Increases the Risk of Spontaneous Bacterial Peritonitis in Patients with HBV-Related Acute-on-Chronic Liver Failure

INTRODUCTION

Spontaneous bacterial peritonitis (SBP) is a common infection in patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF). SBP significantly increases the mortality rate and medical costs. The association between proton pump inhibitor (PPI) use and SBP remains unclear. We conducted a retrospective study to investigate the association between PPI use and SBP in patients with HBV-related ACLF and to explore the risk factors for SBP.

METHODS

We compared the SBP incidence between the PPI and non-PPI groups before and after propensity score matching and explored the association between the duration and type of PPI and SBP occurrence. Risk factors for SBP occurrence were determined by univariate and multivariate logistic regression analysis.

RESULTS

The SBP incidence was higher in the PPI group than in the non-PPI group before and after propensity score matching. The SBP incidence increased for elevated MELD scores in PPI users. There was a similar SBP incidence in both different types and durations of PPI users. MELD score, old age, male sex, and high WBC count were significant independent risk factors for SBP in PPI users with HBV-related ACLF in the hospital.

CONCLUSIONS

PPI therapy increases the risk of SBP development in patients with HBV-related ACLF. MELD score, old age, male sex, and high WBC count could serve as predictors of SBP in PPI users. Caution should be taken regarding PPI use, especially for patients with MELD scores > 30.

APASL guidance on stopping nucleos(t)ide analogues in chronic hepatitis B patients

Chronic hepatitis B virus (HBV) infection is currently incurable. Long-term treatment with potent and safe nucleos(t)ide analogs (NAs) can reduce hepatocellular carcinoma (HCC) and cirrhosis-related complications through profound viral suppression. However, indefinite therapy raises several crucial issues with pros and cons. Because seroclearance of hepatitis B surface (HBsAg) as functional cure is not easily achievable, a finite therapy including sequential 48-week pegylated interferon therapy may provide an opportunity to facilitate HBsAg seroclearance by the rejuvenation of exhausted immune cells. However, the cost of stopping NA is the high incidence of virological relapse and surge of alanine aminotransferase (ALT) levels, which may increase the risk of adverse outcomes (e.g., decompensation, fibrosis progression, HCC, or liver-related mortality). So far, the APASL criteria to stop NA treatment is undetectable HBV DNA levels with normalization of ALT; however, this criterion for cessation of treatment is associated with various incidence rates of virological/clinical relapse and more than 40% of NA-stoppers eventually receive retreatment. A very intensive follow-up strategy and identification of low-risk patients for virological/clinical relapse by different biomarkers are the keys to stop the NA treatment safely. Recent studies suggested that decreasing HBsAg level at the end-of-treatment to < 100-200 IU/mL seems to be a useful marker for deciding when to discontinue NAs therapy. In addition, several viral and host factors have been reviewed for their potential roles in predicting clinical relapse. Finally, the APASL guidance has proposed rules to stop NA and the subsequent follow-up strategy to achieve a better prognosis after stopping NA. In general, for both HBeAg-positive and HBeAg-negative patients who have stopped treatment, these measurements should be done every 1-3 months at the minimum until 12 months.

Human immune repertoire in hepatitis B virus infection

Hepatitis B virus (HBV) infection is a public health threat that affects 257 million people worldwide and can progress to liver cirrhosis, liver failure, and hepatocellular carcinoma. The HBV antigen- induced adaptive immune response plays an important role in HBV clearance. Immune repertoire sequencing (IRS) has been used to investigate the molecular mechanisms behind the immune system, find novel ways to treat HBV infection, and evaluate the genetic responses and immune characteristics of individuals infected by HBV or immunized by HBV vaccine. This review summarizes the human immune repertoire analysis methodology, and the application of the IRS in the prediction of HBV infection progression, treatment, and vaccination.

Different Effects of Total Bilirubin on 90-Day Mortality in Hospitalized Patients With Cirrhosis and Advanced Fibrosis: A Quantitative Analysis

Introduction: Total bilirubin (TB) is a major prognosis predictor representing liver failure in patients with acute on chronic liver failure (ACLF). However, the cutoff value of TB for liver failure and whether the same cutoff could be applied in both cirrhotic and non-cirrhotic patients remain controversial. There is a need to obtain the quantitative correlation between TB and short-term mortality via evidence-based methods, which is critical in establishing solid ACLF diagnostic criteria.

Methods: Patients hospitalized with cirrhosis or advanced fibrosis (FIB-4 > 1.45) were studied. TB and other variables were measured at baseline. The primary outcome was 90-day transplantation-free mortality. Multi-variable Cox proportional hazard model was used to present the independent risk of mortality due to TB. Generalized additive model and second derivate (acceleration) were used to plot the “TB-mortality correlation curves.” The mathematical (maximum acceleration) and clinical (adjusted 28-day transplantation-free mortality rate reaching 15%) TB cutoffs for liver failure were both calculated.

Results: Among the 3,532 included patients, the number of patients with cirrhosis and advanced fibrosis were 2,592 and 940, respectively, of which cumulative 90-day mortality were 16.6% (430/2592) and 7.4% (70/940), respectively. Any increase of TB was found the independent risk factor of mortality in cirrhotic patients, while only TB >12 mg/dL independently increased the risk of mortality in patients with advanced fibrosis. In cirrhotic patients, the mathematical TB cutoff for liver failure is 14.2 mg/dL, with 23.3% (605/2592) patients exceeding it, corresponding to 13.3 and 25.0% adjusted 28- and 90-day mortality rate, respectively. The clinical TB cutoff for is 18.1 mg/dL, with 18.2% (471/2592) patients exceeding it. In patients with advanced fibrosis, the mathematical TB cutoff is 12.1 mg/dL, 33.1% (311/940) patients exceeding it, corresponding to 2.9 and 8.0% adjusted 28- and 90-day mortality rate, respectively; the clinical TB cutoff was 36.0 mg/dL, 1.3% (12/940) patients above it.

Conclusion: This study clearly demonstrated the significantly different impact of TB on 90-day mortality in patients with cirrhosis and advanced fibrosis, proving that liver failure can be determined by TB alone in cirrhosis but not in advanced fibrosis. The proposed TB cutoffs for liver failure provides solid support for the establishment of ACLF diagnostic criteria.

Remoteness of residence predicts tumor stage, receipt of treatment, and mortality in patients with hepatocellular carcinoma

Background and Aim

Surveillance and early detection and curative treatment of hepatocellular carcinoma (HCC) are the mainstay of improving survival for patients, but there are several barriers to achieving this goal. We reported the impact of remoteness of residence on receipt of treatment, tumor stage, and survival in patients with HCC in Queensland.

Methods

We conducted a retrospective cohort study of 1651 HCC patients (147 migrants) from 1 January 2007 to 31 December 2016. We used Wilcoxon rank‐sum test to compare the median age at the time of diagnosis and Bayesian Weibull accelerated failure time regression to identify independent predictors of time to death.

Results

The median survival time after HCC diagnosis was 9.0 months (interquartile range 2.0–24.0). Metropolitan residence (P = 0.02), non‐English language (P < 0.001), foreign country of origin (P < 0.001), and HBV etiology (P < 0.001) were significantly associated with receiving surgical resection for HCC treatment. The strongest predictors of time to death were undifferentiated tumor at presentation (time ratio [TR] = 0.30, 95% credible interval (CrI) 0.23–0.39), age ≥70 years (TR = 0.42, 95% CrI 0.34–0.53), living in remote areas (TR = 0.67, 95% CrI 0.55–0.80), and presence of ≥1 comorbidity (TR = 0.69 95% CrI 0.54–0.90). All the other covariates adjusted, including country of birth (TR = 0.76, 95% CrI 0.49–1.06), did not predict survival time.

Conclusions

Patients living in rural and remote areas had late stage clinical presentation and poor survival. Remoteness of residence may limit access to HCC surveillance in at‐risk patients such as those with cirrhosis, and timely curative treatment to improve survival in these patients.

Medication Non-adherence Prevalence and Determinants in Children and Adolescents with Chronic Liver Diseases

Background: Medication adherence is one of the most important challenges in chronic diseases. Objectives: In this study, we investigated medication adherence prevalence among children with chronic liver diseases. Methods: A total of 160 children with chronic liver disease were enrolled in our study. We evaluated medication adherence using the 8-item Morisky Medication Adherence Scale (MMAS-8) and classified them based on the scores (score < 6 = low adherence, scores 6 - 8 = medium adherence, and > 8 = high adherence). Logistic regression recognized final influencing variables on adherence. Results: Of 160 patients, 84 (52.5%) were female, and the mean age of patients was 11.2 ± 4.4 years. Also, 56 participants (35%) were high adherers, and 66 (41.25%) were low adherers. The most common reason for low adherence was forgetfulness in 37 patients (23.13%) and low access to medication in 21 subjects (13.13%). In multivariate logistic regression, age, housing status, and underlying disease were significantly associated with medication adherence. Conclusions: Almost half of the children with chronic liver disease demonstrated low medication adherence. Age, housing status, and underlying disease were significantly associated with medication adherence. We should implement programs to reduce medication non-adherence among children with chronic liver disease.

Association of 5-Hydroxytryptamine 3 Receptor Antagonists With the Prognosis of Liver Failure

Liver failure is a severe clinical syndrome with high mortality. 5-Hydroxytryptamine 3 receptor antagonists (5-HT3RAs) can reduce liver damage in animal models. We investigated whether 5-HT3RAs may improve the prognosis of liver failure. We analyzed the 28 and 90 days mortality of liver failure patients in relation to the use of 5-HT3RAs using data from a tertiary hospital in northwest China. According to the use of 5-HT3RAs, 419 patients with liver failure (46 acute, 93 sub-acute, 44 chronic, 236 acute on chronic) were divided into 5-HT3RA group (n = 105) and control group (n = 314). 5-HT3RAs were associated with decreased 28 days (HR 0.18, 95% CI 0.10-0.34, p < 0.001) and 90 days (HR 0.21, 95% CI 0.13-0.33, p < 0.001) mortality. After propensity score matching (PSM) (n = 67 in each group), 5-HT3RAs were still significantly associated with reduced 28 days (HR 0.10, 95%CI 0.04-0.26, p < 0.001) and 90 days (HR 0.16, 95%CI 0.08-0.31, p < 0.001) mortality. 5-HT3RA group patients had significantly higher 28 and 90 days survivals than controls both before and after PSM (all p < 0.001). This study shows that 5-HT3RAs are associated with increased survival of liver failure patients and thus may be used to treat liver failure if the findings are confirmed by additional studies.

The dynamic of platelet count as a novel and valuable predictor for 90-day survival of hepatitis B virus-related acute-on-chronic liver failure patients

BACKGROUND

The prognosis of hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is extremely poor due to multiple organ dysfunction.

OBJECTIVES

To investigate the prognostic risk factors and create a 90-day prognostic predictive model for the patients with HBV-ACLF.

METHODS

Demographic information, clinical examination, and laboratory test results of the enrolled patients were collected to study the prognostic risk factors. Univariate and multivariate analysis and stepwise Logistic regression were performed to develop the predictive model. External validation was performed to verify the model.

RESULTS

A total of 333 HBV-ACLF patients and 86 HBV-non-ACLF patients were included in this study. Age, alpha-fetoprotein (AFP), total bilirubin (TBIL), platelet (PLT), and international normalized ratio (INR) were found to be independent risk factors for poor outcomes of HBV-ACLF patients. The formula identified for the linear predictor (LP) of the prognosis of HBV-ACLF patients is thus: LP_ACLF=-5.04-0.056×age-0.002×AFP-0.010×PLT+0.002×TBIL+0.877×INR. The area under curve (AUC) of the receiver operating characteristic curve (ROC) was 0.7835 (95% CI 0.7248-0.8423).

CONCLUSIONS

A predictive model with good calibration and discrimination for 90-day survival of HBV-ACLF patients, including 5 variables, namely age, AFP, PLT, TBIL, and INR was established. Platelet count was a sensitive and dynamic variable for the prognosis of HBV-ACLF.

Acute-on-chronic liver failure: Definitions, pathophysiology and principles of treatment

The term acute-on-chronic liver failure (ACLF) defines an abrupt and life-threatening worsening of clinical conditions in patients with cirrhosis or chronic liver disease. In recent years, different definitions and diagnostic criteria for the syndrome have been proposed by the major international scientific societies. The main controversies relate to the type of acute insult (specifically hepatic or also extrahepatic), the stage of underlying liver disease (cirrhosis or chronic hepatitis) and the concomitant extrahepatic organ failure(s) that should be considered in the definition of ACLF. Therefore, different severity criteria and prognostic scores have been proposed and validated. Current evidence shows that the pathophysiology of ACLF is closely associated with an intense systemic inflammation sustained by circulating pathogen-associated molecular patterns and damage-associated molecular patterns. The development of organ failures may be a result of a combination of tissue hypoperfusion, direct immune-mediated damage and mitochondrial dysfunction. Management of ACLF is currently based on the supportive treatment of organ failures, mainly in an intensive care setting. For selected patients, liver transplantation is an effective treatment that offers a good long-term prognosis. Future studies on potential mechanistic treatments that improve patient survival are eagerly awaited.

Development of a novel score for the diagnosis of bacterial infection in patients with acute-on-chronic liver failure

BACKGROUND

The diagnosis of bacterial infection is difficult in patients with acute-on-chronic liver failure (ACLF).

AIM

To evaluate the diagnostic accuracy of widely used parameters for bacterial infection in ACLF and to develop a simple scoring system to improve diagnostic efficiency.

METHODS

This was a retrospective study. Procalcitonin (PCT), white blood cells (WBC), proportion of neutrophils (N%), and C-reactive protein (CRP) were examined. Logistic regression was used to select variables for the scoring models and receiver operating characteristic curve (ROC) analysis was used to evaluate the diagnostic value of different indices.

RESULTS

This study included 386 patients with ACLF, 169 (43.78%) of whom had bacterial infection on admission. The area under the ROC (AUROC) of PCT, CRP, WBC and N% for the diagnosis of bacterial infection ranged from 0.637 to 0.692, with no significant difference between them. Logistic regression showed that only N%, PCT, and CRP could independently predict infection. A novel scoring system (infection score) comprised of N%, PCT and CRP was developed. The AUROC of the infection score was 0.740, which was significantly higher than that for the other four indices (infection score vs N%, PCT, CRP, and WBC, P = 0.0056, 0.0001, 0.0483 and 0.0008, respectively). The best cutoff point for the infection score was 4 points, with a sensitivity of 78.05%, a specificity of 55.29%, a positive predictive value of 57.91% and a negative predictive value of 76.16%.

CONCLUSION

The infection score is a simple and useful tool for discriminating bacterial infection in ACLF.

Plasma perfusion combined with plasma exchange in chronic hepatitis B-related acute-on-chronic liver failure patients

BACKGROUND AND AIMS

Artificial liver support systems (ALSS) have been shown to significantly reduce mortality in patients with acute-on-chronic liver failure (ACLF). However, the characteristics of patients who would benefit most from ALSS treatment are poorly understood. This study aimed to delineate the indicators for ALSS and evaluate the effectiveness of plasma perfusion combined with plasma exchange (PP + PE) in patients with hepatitis B virus-related ACLF (HBV-ACLF).

METHODS

A total of 898 patients with HBV-ACLF in a single center were enrolled retrospectively. Propensity score matching (PSM) was used in case-paired analysis. Hepatic or extra-hepatic organ failures were defined by Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) criteria. Complications included ascites, infection, hepatopulmonary syndrome, hepatorenal syndrome, hepatic encephalopathy and upper gastrointestinal bleeding. Numbers of organ failures or complications were used for risk stratification.

RESULTS

Among all patients, 418 patients received standard medical therapy (SMT) and 480 received PP + PE plus SMT. After one-to-one paired PSM within the two groups without risk stratification, 293 pairs were enrolled. The PP + PE group displayed significantly lower mortality risk in both 28- and 90-day observation durations. When stratified, patients with two or more organ failures or complications from the PP + PE group showed greater decrease in mortality risk. Moreover, PP + PE treatment significantly increased the resolution of organ failures and complications and ameliorated the development of new organ failures and complications.

CONCLUSIONS

PP + PE treatment significantly reversed organ failures and ameliorated the development of new organ failures and complications, thus reducing mortality risk of patients with HBV-ACLF.

The Risk of Acute Kidney Injury in Hepatitis B Virus-Related Acute on Chronic Liver Failure with Tenofovir Treatment

Aims

Tenofovir (TDF) is an antiviral drug with potential risk of kidney injury. The study is aimed at comparing the incidence of acute kidney injury (AKI) between TDF and entecavir (ETV) treatment in hepatitis B virus- (HBV-) related acute on chronic liver failure (ACLF).

Methods

Treatment-naive patients with HBV-related ACLF were included. Propensity score matching was used to balance the baseline characteristics between ETV and TDF groups. The risk of AKI and the efficacy of TDF and ETV were compared.

Results

A total of 95 cases with HBV-related ACLF were included in this study, with 74.74% of male and a mean age of 47.01 ± 14.71 years. The antiviral therapy was initiated within 2 days after admission, with 39 cases on the TDF group and 56 on the ETV group. Patients in the TDF group had higher AST, hemoglobin, and serum sodium levels and lower MELD-Na score. After propensity matching, 39 cases of TDF and 39 of ETV were included in the final analysis. No difference was found in the changes of creatinine and cystatin C from baseline to 4 weeks after treatment between ETV and TDF groups. AKI was developed in 1 (2.56%) patient in the ETV group and 2 (5.13%) in the TDF group within one month (P = 0.556). Survival analysis revealed no significant difference in the 6-month mortality between the two groups (P = 0.813). Cox analysis showed that the type of antiviral drug or the development of AKI was not an independent risk factor for the outcomes.

Conclusions

Compared to ETV, TDF did not increase the risk of AKI nor the mortality in patients with HBV-related ACLF in the short time.

Effect of artificial liver support system on short-term prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure

Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is difficult to treat and carries a high risk of short-term mortality. This study aimed to explore the effect of artificial liver support system (ALSS) on the survival of HBV-ACLF patients and to investigate which HBV-ACLF patients may benefit from ALSS treatment. We enrolled 132 patients hospitalized for HBV-ACLF according to the criteria of the Chinese Group on the Study of Severe Hepatitis B-ACLF (COSSH-ACLF) from 425 ACLF patients who were determined to at least meet the Asian Pacific Association for the Study of the Liver criteria and followed up for 90 days. Overall 132 eligible patients were divided into two groups: standard medical treatment (SMT) group, which included 54 patients who underwent SMT alone, and ALSS group, which included 78 patients who underwent ALSS treatment plus SMT. The proportion of HBV-ACLF grade 1, 2, and 3 was 57.69%, 37.18%, and 5.13% in the ALSS group and 51.85%, 35.19%, and 12.96% in the SMT group, respectively. Bacterial infection was present in 43.6% of patients in the ALSS group and in 55.6% of patients in the SMT group. The mortality rates in the ALSS group at 28 and 90 days were significantly lower than those in the SMT group (23.08% vs. 48.15% and 33.33% vs. 57.41%, P < 0.05). ALSS was an independent factor related to both the 28- and 90-day survival of HBV-ACLF patients. Particularly, a higher cumulative survival rate in either patients with HBV-ACLF grade 1 or those with HBV-ACLF with bacterial infection was observed in the ALSS group. Moreover, ALSS had an independent influence on mortality. Based on the COSSH-ACLF criteria, ALSS could better improve the short-term survival of HBV-ACLF patients than SMT alone, especially in those with HBV-ACLF grade 1 or HBV-ACLF with infection.