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Mafi VIP, Soldera J. Palliative care for end-stage liver disease and acute on chronic liver failure: A systematic review. World J Methodol 2024; 14:95904. [DOI: 10.5662/wjm.v14.i4.95904] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2024] [Revised: 06/20/2024] [Accepted: 07/03/2024] [Indexed: 07/26/2024] Open
Abstract
BACKGROUND End stage liver disease (ESLD) represents a growing health concern characterized by elevated morbidity and mortality, particularly among individual ineligible for liver transplantation. The demand for palliative care (PC) is pronounced in patients grappling with ESLD and acute on chronic liver failure (ACLF). Unfortunately, the historical underutilization of PC in ESLD patients, despite their substantial needs and those of their family caregivers, underscores the imperative of seamlessly integrating PC principles into routine healthcare practices across the entire disease spectrum.
AIM To comprehensively investigate the evidence surrounding the benefits of incorporating PC into the comprehensive care plan for individuals confronting ESLD and/or ACLF.
METHODS A systematic search in the Medline (PubMed) database was performed using a predetermined search command, encompassing studies published in English without any restrictions on the publication date. Subsequently, the retrieved studies were manually examined. Simple descriptive analyses were employed to summarize the results.
RESULTS The search strategies yielded 721 references. Following the final analysis, 32 full-length references met the inclusion criteria and were consequently incorporated into the study. Meticulous data extraction from these 32 studies was undertaken, leading to the execution of a comprehensive narrative systematic review. The review found that PC provides significant benefits, reducing symptom burden, depressive symptoms, readmission rates, and hospital stays. Yet, barriers like the appeal of transplants and misconceptions about PC hinder optimal utilization. Integrating PC early, upon the diagnosis of ESLD and ACLF, regardless of transplant eligibility and availability, improves the quality of life for these patients.
CONCLUSION Despite the substantial suffering and poor prognosis associated with ESLD and ACLF, where liver transplantation stands as the only curative treatment, albeit largely inaccessible, PC services have been overtly provided too late in the course of the illness. A comprehensive understanding of PC's pivotal role in treating ESLD and ACLF is crucial for overcoming these barriers, involving healthcare providers, patients, and caregivers.
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Affiliation(s)
- Vakaola I Pulotu Mafi
- Post-Graduate Program, Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
| | - Jonathan Soldera
- Post-Graduate Program, Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
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Fernandes FC, Boteon APCDS, Rossi GG, Marques F, Della-Guardia B, Boteon YL. Acute-on-chronic liver failure: a retrospective review of cases at a transplantation center in Brazil. Acta Cir Bras 2024; 39:e392624. [PMID: 38896629 PMCID: PMC11178148 DOI: 10.1590/acb392624] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Accepted: 10/19/2023] [Indexed: 06/21/2024] Open
Abstract
PURPOSE Acute-on-chronic liver failure (ACLF) is a leading cause of death in cirrhotic patients. This study aims to describe the outcomes of in-patients with ACLF at a liver transplantation (LT) center in Brazil. METHODS Retrospective study analyzing patient data from 2017 to 2022. Re-transplant cases and patients without previous chronic liver disease were excluded. The ACLF diagnosis was based on the European Association for the Study of the Liver-Chronic Liver Failure criteria and assessments repeated on days 3 and 7 after the initial diagnosis. RESULTS Among 381 patients, 10.49% (n = 40) were diagnosed with ACLF. Bacterial infection was the most common precipitating factor (45%). Kidney failure occurred in 65% of the cases. The 28-day mortality rate was 35% and varied according to ACLF severity at diagnosis, from single organ failure (ACLF-1) at 22% to three organ failures (ACLF-3) at 60%. Eighteen patients (45%) were transplanted with a 100% 28-day survival rate. For ACLF-3 cases at diagnosis (n = 15), the 28-day and 1-year survival rates with a transplant (n = 4) were 100% and 80%, respectively, and without transplant (n = 11), 10 and 0%, respectively. CONCLUSIONS ACLF was associated with high mortality rates. LT was an effective therapeutic option, particularly for ACLF-3 cases.
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Affiliation(s)
| | | | - Giovana Garcia Rossi
- Faculdade Israelita de Ciências da Saúde Albert Einstein – São Paulo (SP) – Brazil
| | | | | | - Yuri Longatto Boteon
- Faculdade Israelita de Ciências da Saúde Albert Einstein – São Paulo (SP) – Brazil
- Hospital Israelita Albert Einstein – São Paulo (SP) – Brazil
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3
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Idalsoaga F, Díaz LA, Fuentes-López E, Ayares G, Valenzuela F, Meza V, Manzur F, Sotomayor J, Rodriguez H, Chianale F, Villagrán S, Schalper M, Villafranca P, Veliz MJ, Uribe P, Puebla M, Bustamante P, Aguirre H, Busquets J, Roblero JP, Mezzano G, Hernandez-Tejero M, Arrese M, Arab JP. Active alcohol consumption is associated with acute-on-chronic liver failure in Hispanic patients. GASTROENTEROLOGIA Y HEPATOLOGIA 2024; 47:562-573. [PMID: 37778718 DOI: 10.1016/j.gastrohep.2023.09.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 09/16/2023] [Accepted: 09/18/2023] [Indexed: 10/03/2023]
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a severe clinical entity associated with elevated short-term mortality. We aimed to characterize patients with decompensated cirrhosis according to presence of ACLF, their association with active alcohol intake, and long-term survival in Latin America. METHODS Retrospective cohort study of decompensated cirrhotic in three Chilean university centers (2017-2019). ACLF was diagnosed according EASL-CLIF criteria. We assessed survival using competing-risk and time-to-event analyses. We evaluated the time to death using accelerated failure time (AFT) models. RESULTS We included 320 patients, median age of 65.3±11.7 years old, and 48.4% were women. 92 (28.7%) patients met ACLF criteria (ACLF-1: 29.3%, ACLF-2: 27.1%, and ACLF-3: 43.4%). The most common precipitants were infections (39.1%), and the leading organ failure was kidney (59.8%). Active alcohol consumption was frequent (27.7%), even in patients with a prior diagnosis of non-alcoholic fatty liver disease (NAFLD) (16.2%). Ninety-two (28.7%) patients had ACLF (ACLF-1: 8.4%, ACLF-2: 7.8%, and ACLF-3: 12.5%). ACLF patients had a higher MELD-Na score at admission (27 [22-31] versus 16 [12-21], p<0.0001), a higher frequency of alcohol-associated liver disease (36.7% versus 24.9%, p=0.039), and a more frequent active alcohol intake (37.2% versus 23.8%, p=0.019). In a multivariate model, ACLF was associated with higher mortality (subdistribution hazard ratio 1.735, 95%CI: 1.153-2.609; p<0.008). In the AFT models, the presence of ACLF during hospitalization correlated with a shorter time to death: ACLF-1 shortens the time to death by 4.7 times (time ratio [TR] 0.214, 95%CI: 0.075-0.615; p<0.004), ACLF-2 by 4.4 times (TR 0.224, 95%CI: 0.070-0.713; p<0.011), and ACLF-3 by 37 times (TR 0.027, 95%CI: 0.006-0.129; p<0.001). CONCLUSIONS Patients with decompensated cirrhosis and ACLF exhibited a high frequency ofactive alcohol consumption. Patients with ACLF showed higher mortality and shorter time todeath than those without ACLF.
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Affiliation(s)
- Francisco Idalsoaga
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Luis Antonio Díaz
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Eduardo Fuentes-López
- Departamento de Ciencias de la Salud, Facultad de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Gustavo Ayares
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Francisco Valenzuela
- Departamento de Medicina Interna, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Victor Meza
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Franco Manzur
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Joaquín Sotomayor
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Hernán Rodriguez
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Franco Chianale
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Sofía Villagrán
- Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | | | | | | | - Paz Uribe
- Escuela de Medicina, Universidad de Chile, Santiago, Chile
| | | | - Pablo Bustamante
- Departamento de Medicina, Sección Gastroenterología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Herman Aguirre
- Departamento de Medicina, Sección Gastroenterología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Javiera Busquets
- Departamento de Medicina, Sección Gastroenterología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Juan Pablo Roblero
- Departamento de Medicina, Sección Gastroenterología, Hospital Clínico Universidad de Chile, Universidad de Chile, Santiago, Chile
| | - Gabriel Mezzano
- Sección de Gastroenterología, Hospital del Salvador, Santiago, Chile; Centro de Enfermedades Digestivas, Universidad de los Andes, Santiago, Chile
| | - Maria Hernandez-Tejero
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN, USA; Liver Unit, Hospital Clinic, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
| | - Marco Arrese
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
| | - Juan Pablo Arab
- Departamento de Gastroenterología, Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile; Division of Gastroenterology, Department of Medicine, Schulich School of Medicine, Western University & London Health Sciences Centre, London, Ontario, Canada; Department of Epidemiology and Biostatistics, Schulich School of Medicine, Western University, London, Ontario, Canada.
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Aggarwal A, Biswas S, Arora U, Vaishnav M, Shenoy A, Swaroop S, Agarwal A, Elhence A, Kumar R, Goel A, Shalimar. Definitions, Etiologies, and Outcomes of Acute on Chronic Liver Failure: A Systematic Review and Meta-analysis. Clin Gastroenterol Hepatol 2024:S1542-3565(24)00425-7. [PMID: 38750869 DOI: 10.1016/j.cgh.2024.04.018] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2024] [Revised: 04/02/2024] [Accepted: 04/02/2024] [Indexed: 06/10/2024]
Abstract
BACKGROUND & AIMS Acute-on-chronic liver failure (ACLF) is a major public health concern. We aimed to assess the definitions, etiologic spectrum, organ failure (OF), and outcomes of ACLF globally. METHODS Three databases were searched for studies on ACLF from 1990 until September 2022. Information regarding definitions, acute precipitants, underlying chronic liver disease (CLD), OF, and mortality were extracted. Meta-analyses were performed for pooled prevalence rates (95% confidence interval [CI]) using random-effects model for each definition of ACLF. RESULTS Of the 11,451 studies identified, 114 articles (142 cohorts encompassing 210,239 patients) met the eligibility criteria. Most studies (53.2%) used the European Association for the Study of the Liver (EASL) definition, followed by Asia-Pacific Association for the Study of the Liver (APASL) (33.3%). Systemic infection was the major acute precipitant, and alcohol use was the major cause of CLD in EASL-defined studies, whereas alcohol was both the major acute precipitant and cause of CLD in APASL-defined studies. Liver failure was the major OF in APASL-based studies, whereas renal failure was predominant in EASL-based studies. Thirty-day mortality varied across definitions: APASL: 38.9%, 95% CI, 31.2%-46.9%; EASL: 47.9%, 95% CI, 42.2%-53.5%; and NACSELD: 52.2%, 95% CI, 51.9%-52.5%. Diagnostic overlap between definitions ranged from 7.7% to 80.2%. Meta-regression suggested that the World Health Organization region influenced 30-day mortality in studies using EASL definition. CONCLUSIONS Heterogeneity in the definition of ACLF proposed by different expert societies and regional preferences in its use result in differences in clinical phenotype and outcomes. A uniform definition would enhance the comparability and interpretation of global data.
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Affiliation(s)
- Arnav Aggarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Sagnik Biswas
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Umang Arora
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Manas Vaishnav
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Abhishek Shenoy
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Shekhar Swaroop
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Ayush Agarwal
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Anshuman Elhence
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India
| | - Ramesh Kumar
- Department of Gastroenterology, All India Institute of Medical Sciences, Patna, India
| | - Amit Goel
- Department of Hepatology, Sanjay Gandhi Institute of Medical Sciences, Lucknow, India
| | - Shalimar
- Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, Delhi, India.
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Valainathan SR, Xie Q, Arroyo V, Rautou PE. Prognosis algorithms for acute decompensation of cirrhosis and ACLF. Liver Int 2024. [PMID: 38591751 DOI: 10.1111/liv.15927] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/22/2024] [Revised: 03/14/2024] [Accepted: 03/26/2024] [Indexed: 04/10/2024]
Abstract
Accurate prediction of survival in patients with cirrhosis is crucial, as patients who are unlikely to survive in the short-term need to be oriented to liver transplantation and to novel therapeutic approaches. Patients with acute decompensation of cirrhosis without or with organ dysfunction/failure, the so-called acute-on-chronic liver failure (ACLF), have a particularly high short-term mortality. Recognizing the specificity of this clinical situation, dedicated classifications and scores have been developed over the last 15 years, including variables (e.g. organ failures and systemic inflammation) not part of the formerly available cirrhosis severity scores, namely Child-Pugh score or MELD. For patients with acute decompensation of cirrhosis, it led to the development of a dedicated score, the Clif-C-AD score, independently validated. For more severe patients, three different scoring systems have been proposed, by European, Asian and North American societies namely Clif-C-ACLF, AARC score and NASCELD-ACLF respectively. These scores have been validated, and are widely used across the world. The differences and similarities between these scores, as well as their validation and limitations are discussed here. Even if these scores and classifications have been a step forward in favouring homogeneity between studies, and in helping making decisions for individual patients, their predictive value for mortality can still be improved as their area under the ROC curve does not exceed .8. Novel scores including biomarkers reflecting the pathophysiology of acute decompensation of cirrhosis might help reach that goal.
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Affiliation(s)
- Shantha R Valainathan
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
- Service de Réanimation polyvalente Centre hospitalier Victor Dupouy, Argenteuil, France
| | - Qing Xie
- Department of Infectious Diseases, Ruijin Hospital Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Vicente Arroyo
- European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain
| | - Pierre-Emmanuel Rautou
- Université Paris-Cité, Inserm, Centre de recherche sur l'inflammation, UMR 1149, Paris, France
- AP-HP, Hôpital Beaujon, Service d'Hépatologie, DMU DIGEST, Centre de Référence des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Clichy, France
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Kampelos G, Alexopoulos T, Vasilieva L, Mani I, Hadziyannis E, Giannouli S, Manioudaki S, Nomikou E, Alexopoulou A. A combination of clot formation abnormalities in thromboelastometry has a high prognostic value in patients with acute-on-chronic liver failure. Eur J Gastroenterol Hepatol 2024; 36:76-82. [PMID: 37823404 DOI: 10.1097/meg.0000000000002630] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/13/2023]
Abstract
BACKGROUND Global coagulation tests offer a better tool to assess procoagulant and anticoagulant pathways, fibrinolysis and clot firmness and evaluate more accurately coagulation defects compared to conventional coagulation tests. Their prognostic role in acute-on-chronic liver disease (ACLF) or acute decompensation (AD) has not been well established. AIMS To assess the properties and prognostic value of the coagulation profile measured by rotational thromboelastometry (ROTEM) in ACLF and AD. METHODS 84 consecutive patients (35 ACLF and 49 AD) were prospectively studied. Twenty healthy persons matched for age and gender were used as controls. 'Hypocoagulable' or 'hypercoagulable' profiles on admission were assessed based on nine ROTEM parameters and mortality was recorded at 30 and 90 days. RESULTS Individual ROTEM parameters denoted significantly more hypocoagulability in patients compared to controls. 'Hypocoagulable' profile (defined as a composite of 4 or more ROTEM parameters outside the range) was associated with more severe liver disease assessed either as MELD or Child-Pugh scores ( P < 0.001 for both) and higher 30-day mortality (Log-rank P = 0.012). 'Hypocoagulable' profile (HR 3.160, 95% CI 1.003-9.957, P = 0.049) and ACLF status (HR 23.786, 95% CI 3.115-181.614, P = 0.002) were independent predictors of 30-day mortality, in multivariate model. A higher early mortality rate was shown in ACLF patients with 'hypocoagulable' phenotype compared to those without (Log-rank P = 0.017). 'Hypocoagulable' profile was not associated with mortality in AD. CONCLUSION 'Hypocoagulable' profile was associated with more advanced liver disease and higher short-term mortality in patients with ACLF.
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Affiliation(s)
- George Kampelos
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| | - Theodoros Alexopoulos
- Gastroenterology Department, National & Kapodistrian University of Athens, Medical School, Laiko General Hospital
| | | | - Iliana Mani
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| | - Emilia Hadziyannis
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| | - Stavroula Giannouli
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
| | | | - Efrosyni Nomikou
- Blood Bank and Haemophilia Unit, Hippokratio General Hospital of Athens, Athens, Greece
| | - Alexandra Alexopoulou
- 2nd Department of Internal Medicine and Research Laboratory, Medical School, National & Kapodistrian University of Athens, Hippokration General Hospital
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Essing T, Bock H, Wieland B, Fluegen G, Bednarsch J, Bode JG, Neumann UP, Roderburg C, Loosen SH, Luedde T. Clinical determinants of hospital mortality in liver failure: a comprehensive analysis of 62,717 patients. ZEITSCHRIFT FUR GASTROENTEROLOGIE 2023; 61:1472-1483. [PMID: 36972596 DOI: 10.1055/a-2016-9061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/29/2023]
Abstract
BACKGROUND Liver failure (LF) is characterised by a loss of the synthetic and metabolic liver function and is associated with a high mortality. Large-scale data on recent developments and hospital mortality of LF in Germany are missing. A systematic analysis and careful interpretation of these datasets could help to optimise outcomes of LF. METHODS We used standardised hospital discharge data of the Federal Statistical Office to evaluate current trends, hospital mortality and factors associated with an unfavourable course of LF in Germany between 2010 and 2019. RESULTS A total of 62,717 hospitalised LF cases were identified. Annual LF frequency decreased from 6716 (2010) to 5855 (2019) cases and was higher among males (60.51%). Hospital mortality was 38.08% and significantly declined over the observation period. Mortality significantly correlated with patients' age and was highest among individuals with (sub)acute LF (47.5%). Multivariate regression analyses revealed pulmonary (ORARDS: 2.76, ORmechanical ventilation: 6.46) and renal complications (ORacute kidney failure: 2.04, ORhepatorenal syndrome: 2.92) and sepsis (OR: 1.92) as factors for increased mortality. Liver transplantation reduced mortality in patients with (sub)acute LF. Hospital mortality significantly decreased with the annual LF case volume and ranged from 47.46% to 29.87% in low- or high-case-volume hospitals, respectively. CONCLUSIONS Although incidence rates and hospital mortality of LF in Germany have constantly decreased, hospital mortality has remained at a very high level. We identified a number of variables associated with increased mortality that could help to improve framework conditions for the treatment of LF in the future.
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Affiliation(s)
- Tobias Essing
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
- Paracelsus Medical University, Klinikum Nürnberg, Nürnberg, Germany
| | - Hans Bock
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Björn Wieland
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Georg Fluegen
- Department of Surgery (A), University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Jan Bednarsch
- Department of Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Johannes G Bode
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Ulf P Neumann
- Department of Visceral and Transplantation Surgery, University Hospital RWTH Aachen, Aachen, Germany
| | - Christoph Roderburg
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Sven H Loosen
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tom Luedde
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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8
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Ndomba N, Soldera J. Management of sepsis in a cirrhotic patient admitted to the intensive care unit: A systematic literature review. World J Hepatol 2023; 15:850-866. [PMID: 37397933 PMCID: PMC10308287 DOI: 10.4254/wjh.v15.i6.850] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Revised: 05/22/2023] [Accepted: 05/31/2023] [Indexed: 06/25/2023] Open
Abstract
BACKGROUND Sepsis is a severe medical condition that occurs when the body's immune system overreacts to an infection, leading to life-threatening organ dysfunction. The "Third international consensus definitions for sepsis and septic shock (Sepsis-3)" defines sepsis as an increase in sequential organ failure assessment score of 2 points or more, with a mortality rate above 10%. Sepsis is a leading cause of intensive care unit (ICU) admissions, and patients with underlying conditions such as cirrhosis have a higher risk of poor outcomes. Therefore, it is critical to recognize and manage sepsis promptly by administering fluids, vasopressors, steroids, and antibiotics, and identifying and treating the source of infection.
AIM To conduct a systematic review and meta-analysis of existing literature on the management of sepsis in cirrhotic patients admitted to the ICU and compare the management of sepsis between cirrhotic and non-cirrhotic patients in the ICU.
METHODS This study is a systematic literature review that followed the PRISMA statement's standardized search method. The search for relevant studies was conducted across multiple databases, including PubMed, Embase, Base, and Cochrane, using predefined search terms. One reviewer conducted the initial search, and the eligibility criteria were applied to the titles and abstracts of the retrieved articles. The selected articles were then evaluated based on the research objectives to ensure relevance to the study's aims.
RESULTS The study findings indicate that cirrhotic patients are more susceptible to infections, resulting in higher mortality rates ranging from 18% to 60%. Early identification of the infection source followed by timely administration of antibiotics, vasopressors, and corticosteroids has been shown to improve patient outcomes. Procalcitonin is a useful biomarker for diagnosing infections in cirrhotic patients. Moreover, presepsin and resistin have been found to be reliable markers of bacterial infection in patients with decompensated liver cirrhosis, with similar diagnostic performance compared to procalcitonin.
CONCLUSION This review highlights the importance of early detection and management of infections in cirrhosis patients to reduce mortality. Therefore, early detection of infection using procalcitonin test and other biomarker as presepsin and resistin, associated with early management with antibiotics, fluids, vasopressors and low dose corticosteroids might reduce the mortality associated with sepsis in cirrhotic patients.
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Affiliation(s)
- Nkola Ndomba
- Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
| | - Jonathan Soldera
- Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
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9
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Terres AZ, Balbinot RS, Muscope ALF, Longen ML, Schena B, Cini BT, Rost Jr GL, Balensiefer JIL, Eberhardt LZ, Balbinot RA, Balbinot SS, Soldera J. Acute-on-chronic liver failure is independently associated with higher mortality for cirrhotic patients with acute esophageal variceal hemorrhage: Retrospective cohort study. World J Clin Cases 2023; 11:4003-4018. [PMID: 37388802 PMCID: PMC10303600 DOI: 10.12998/wjcc.v11.i17.4003] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2023] [Revised: 04/15/2023] [Accepted: 05/11/2023] [Indexed: 06/12/2023] Open
Abstract
BACKGROUND Acute esophageal variceal hemorrhage (AEVH) is a common complication of cirrhosis and might precipitate multi-organ failure, causing acute-on-chronic liver failure (ACLF).
AIM To analyze if the presence and grading of ACLF as defined by European Society for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) is able to predict mortality in cirrhotic patients presenting AEVH.
METHODS Retrospective cohort study executed in Hospital Geral de Caxias do Sul. Data from medical records from 2010 to 2016 were obtained by searching the hospital electronic database for patients who received terlipressin. Medical records were reviewed in order to determine the diagnosis of cirrhosis and AEVH, including 97 patients. Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis.
RESULTS All- cause mortality for AEVH patients was 36%, 40.2% and 49.4% for 30-, 90- and 365-day, respectively. The prevalence of ACLF was 41.3%. Of these, 35% grade 1, 50% grade 2 and 15% grade 3. In multivariate analysis, the non-use of non-selective beta-blockers, presence and higher grading of ACLF and higher Model for End-Stage Liver Disease scores were independently associated with higher mortality for 30-day with the addition of higher Child-Pugh scores for 90-day period.
CONCLUSION Presence and grading of ACLF according to the EASL-CLIF criteria was independently associated with higher 30- and 90-day mortality in cirrhotic patients admitted due to AEVH.
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Affiliation(s)
- Alana Zulian Terres
- Clinical Gastroenterology, Universidade de Caxias do Sul, Caxias do Sul 95020-002, Brazil
| | | | | | - Morgana Luisa Longen
- School of Medicine, Universidade de Caxias do Sul, Caxias do Sul 95020-002, Brazil
| | - Bruna Schena
- School of Medicine, Universidade de Caxias do Sul, Caxias do Sul 95020-002, Brazil
| | - Bruna Teston Cini
- School of Medicine, Universidade de Caxias do Sul, Caxias do Sul 95020-002, Brazil
| | | | | | | | - Raul Angelo Balbinot
- Clinical Gastroenterology, Universidade de Caxias do Sul, Caxias do Sul 95020-002, Brazil
| | | | - Jonathan Soldera
- Department of Gastroenterology, University of South Wales, Cardiff CF37 1DL, United Kingdom
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10
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Rashed E, Soldera J. CLIF-SOFA and CLIF-C scores for the prognostication of acute-on-chronic liver failure and acute decompensation of cirrhosis: A systematic review. World J Hepatol 2022; 14:2025-2043. [PMID: 36618331 PMCID: PMC9813844 DOI: 10.4254/wjh.v14.i12.2025] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 10/18/2022] [Accepted: 11/07/2022] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Acute-on-chronic liver failure (ACLF) is a syndrome characterized by decompensation in individuals with chronic liver disease, generally secondary to one or more extra-hepatic organ failures, implying an elevated mortality rate. Acute decompensation (AD) is the term used for one or more significant consequences of liver disease in a short time and is the most common reason for hospital admission in cirrhotic patients. The European Association for the Study of Liver-Chronic-Liver Failure (EASL-CLIF) Group modified the intensive care Sequential Organ Failure Assessment score into CLIF-SOFA, which detects the presence of ACLF in patients with or without AD, classifying it into three grades.
AIM To investigate the role of the EASL-CLIF definition for ACLF and the ability of CLIF-SOFA, CLIF-C ACLF, and CLIF-C AD scores for prognosticating ACLF or AD.
METHODS This study is a literature review using a standardized search method, conducted using the steps following the guidelines for reporting systematic reviews set out by the PRISMA statement. For specific keywords, relevant articles were found by searching PubMed, ScienceDirect, and BioMed Central-BMC. The databases were searched using the search terms by one reviewer, and a list of potentially eligible studies was generated based on the titles and abstracts screened. The data were then extracted and assessed on the basis of the Reference Citation Analysis (https://www.referencecitationanalysis.com/).
RESULTS Most of the included studies used the EASL-CLIF definition for ACLF to identify cirrhotic patients with a significant risk of short-term mortality. The primary outcome in all reviewed studies was mortality. Most of the study findings were based on an area under the receiver operating characteristic curve (AUROC) analysis, which revealed that CLIF-SOFA, CLIF-C ACLF, and CLIF-C AD scores were preferable to other models predicting 28-d mortality. Their AUROC scores were higher and able to predict all-cause mortality at 90, 180, and 365 d. A total of 50 articles were included in this study, which found that the CLIF-SOFA, CLIF-C ACLF and CLIF-C AD scores in more than half of the articles were able to predict short-term and long-term mortality in patients with either ACLF or AD.
CONCLUSION CLIF-SOFA score surpasses other models in predicting mortality in ACLF patients, especially in the short-term. CLIF-SOFA, CLIF-C ACLF, and CLIF-C AD are accurate short-term and long-term mortality prognosticating scores.
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Affiliation(s)
- Ebrahim Rashed
- Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
| | - Jonathan Soldera
- Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
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11
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Matiollo C, Rateke ECDM, Moura EQDA, Andrigueti M, Augustinho FCD, Zocche TL, Silva TE, Gomes LO, Farias MR, Narciso-Schiavon JL, Schiavon LL. Elevated calprotectin levels are associated with mortality in patients with acute decompensation of liver cirrhosis. World J Hepatol 2022; 14:1964-1976. [PMID: 36483607 PMCID: PMC9724106 DOI: 10.4254/wjh.v14.i11.1964] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/02/2022] [Revised: 10/18/2022] [Accepted: 11/04/2022] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND Acute decompensation (AD) of cirrhosis is related to systemic inflammation and elevated circulating cytokines. In this context, biomarkers of inflammation, such as calprotectin, may be of prognostic value.
AIM To evaluate serum calprotectin levels in patients hospitalized for complications of cirrhosis.
METHODS This is a prospective cohort study that included 200 subjects hospitalized for complications of cirrhosis, 20 outpatients with stable cirrhosis, and 20 healthy controls. Serum calprotectin was measured by enzyme-linked immunosorbant assay.
RESULTS Calprotectin levels were higher among groups with cirrhosis when compared to healthy controls. Higher median calprotectin was related to Child-Pugh C, ascites, and hepatic encephalopathy. Higher calprotectin was related to acute-on-chronic liver failure (ACLF) and infection in the bivariate, but not in multivariate analysis. Calprotectin was not associated with survival among patients with ACLF; however, in patients with AD without ACLF, higher calprotectin was associated with a lower 30-d survival, even after adjustment for chronic liver failure-consortium (CLIF-C) AD score. A high-risk group (CLIF-C AD score ≥ 60 and calprotectin ≥ 580 ng/mL) was identified, which had a 30-d survival (27.3%) similar to that of patients with grade 3 ACLF (23.3%).
CONCLUSION Serum calprotectin is associated with prognosis in patients with AD without ACLF and may be useful in clinical practice to early identify patients with a very low short-term survival.
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Affiliation(s)
- Camila Matiollo
- Clinical Analysis Laboratory Unit, University Hospital, Federal University of Santa Catarina, Florianopolis 88040-900, Brazil
| | | | | | - Michelle Andrigueti
- Clinical Analysis Laboratory Unit, University Hospital, Federal University of Santa Catarina, Florianopolis 88040-900, Brazil
| | | | - Tamara Liana Zocche
- Division of Gastroenterology, University Hospital, Federal University of Santa Catarina, Florianópolis 88040-900, Brazil
| | - Telma Erotides Silva
- Division of Gastroenterology, University Hospital, Federal University of Santa Catarina, Florianópolis 88040-900, Brazil
| | - Lenyta Oliveira Gomes
- Department of Pharmaceutical Sciences Health Sciences Center, Federal University of Santa Catarina, Florianópolis 88040-370, Brazil
| | - Mareni Rocha Farias
- Department of Pharmaceutical Sciences Health Sciences Center, Federal University of Santa Catarina, Florianópolis 88040-370, Brazil
| | - Janaina Luz Narciso-Schiavon
- Division of Gastroenterology, Department of Internal Medicine, Federal University of Santa Catarina, Florianopolis 88040-900, SC, Brazil
| | - Leonardo Lucca Schiavon
- Division of Gastroenterology, Department of Internal Medicine, Federal University of Santa Catarina, Florianopolis 88040-900, SC, Brazil
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12
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Abstract
This is a protocol for a Cochrane Review (intervention). The objectives are as follows: To assess the benefits and harms of liver support systems for adults with acute‐on‐chronic liver failure.
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13
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Seshadri A, Appelbaum R, Carmichael SP, Cuschieri J, Hoth J, Kaups KL, Kodadek L, Kutcher ME, Pathak A, Rappold J, Rudnick SR, Michetti CP. Management of Decompensated Cirrhosis in the Surgical ICU: an American Association for the Surgery of Trauma Critical Care Committee Clinical Consensus Document. Trauma Surg Acute Care Open 2022; 7:e000936. [PMID: 35991906 PMCID: PMC9345092 DOI: 10.1136/tsaco-2022-000936] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2022] [Accepted: 07/20/2022] [Indexed: 11/04/2022] Open
Abstract
Management of decompensated cirrhosis (DC) can be challenging for the surgical intensivist. Management of DC is often complicated by ascites, coagulopathy, hepatic encephalopathy, gastrointestinal bleeding, hepatorenal syndrome, and difficulty assessing volume status. This Clinical Consensus Document created by the American Association for the Surgery of Trauma Critical Care Committee reviews practical clinical questions about the critical care management of patients with DC to facilitate best practices by the bedside provider.
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Affiliation(s)
- Anupamaa Seshadri
- Department of Surgery, Beth Israel Deaconess Medical Center, Boston, Massachusetts, USA
| | - Rachel Appelbaum
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Samuel P Carmichael
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Joseph Cuschieri
- Department of Surgery, San Francisco General Hospital and Trauma Center, San Francisco, California, USA
| | - Jason Hoth
- Department of Surgery, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
| | - Krista L Kaups
- Department of Surgery, UCSF Fresno, Fresno, California, USA
| | - Lisa Kodadek
- Surgery, Yale University School of Medicine, New Haven, Connecticut, USA,Department of Surgery, Yale New Haven Hospital, New Haven, Connecticut, USA
| | - Matthew E Kutcher
- Surgery, University of Mississippi Medical Center, Jackson, Mississippi, USA
| | - Abhijit Pathak
- Department of Surgery, Temple University School of Medicine, Philadelphia, Pennsylvania, USA
| | - Joseph Rappold
- Department of Surgery, Maine Medical Center, Portland, Oregon, USA
| | - Sean R Rudnick
- Department of Gastroenterology, Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, USA
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14
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Evaluation and management of emergencies in the patient with cirrhosis. REVISTA DE GASTROENTEROLOGÍA DE MÉXICO (ENGLISH EDITION) 2022; 87:198-215. [PMID: 35570104 DOI: 10.1016/j.rgmxen.2022.05.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 11/28/2021] [Indexed: 01/10/2023] Open
Abstract
The approach to and management of critically ill patients is one of the most versatile themes in emergency medicine. Patients with cirrhosis of the liver have characteristics that are inherent to their disease that can condition modification in acute emergency treatment. Pathophysiologic changes that occur in cirrhosis merit the implementation of an analysis as to whether the overall management of a critically ill patient can generally be applied to patients with cirrhosis of the liver or if they should be treated in a special manner. Through a review of the medical literature, the available information was examined, and the evidence found on the special management required by those patients was narratively synthesized, selecting the most representative decompensations within chronic disease that require emergency treatment.
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15
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Zakareya T, Akl M, Shibl S, El-Mazaly M, Abdel-Razek W. Utility of prognostic scores in predicting short-term mortality in patients with acute-on-chronic liver failure. EGYPTIAN LIVER JOURNAL 2022. [DOI: 10.1186/s43066-022-00183-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Acute-on-chronic liver failure (ACLF) is a distinct syndrome associated with high short-term mortality. Early identification of patients at high risk is essential to determine emergency for transplantation and decide and prioritize the need for intensive care unit (ICU). We aimed to evaluate the performance of the different prognostic scores in the prediction of in-hospital mortality in patients with ACLF. A total of 249 patients with ACLF were included and followed till discharge from the hospital. Univariate and Cox regression analyses were used to assess the performance of liver-specific (Child-Pugh and MELD) and ACLF prognostic scores (CLIF-C OF, CLIF-SOFA, CLIF-C AD, CLIF-C ACLF) in the prediction of in-hospital mortality.
Results
Patients were mostly males (71.1%) with a mean age of 53.9 ± 12.8 years. The etiology of pre-existing liver disease was HCV in 57.8%. Sepsis was the most common precipitating factor (49.8%) and the mortality rate was 74.3%. In univariate analysis, all scores were significantly higher in the deceased group (P<0.0001). AUROC were 0.897, 0.884, 0.870, 0.861, 0.861, and 0.850 for CLIF-C OF, CLIF-C AD, CLIF-C ACLF, Child-Pugh, CLIF-SOFA, and MELD scores, respectively. In multivariate analysis, 2 independent predictors of mortality were identified: CLIF-C ACLF score (OR 3.25, 95% CI 1.03–10.25, P<0.0001) and Child-Pugh class C (OR 1.04, 95% CI 1.02–1.06, P=0.044).
Conclusions
All the studied scores could predict in-hospital mortality of patients with ACLF. However, CLIF-C ACLF and Child-Pugh class performed better as they could significantly and independently predict mortality.
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16
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Mezzano G, Juanola A, Cardenas A, Mezey E, Hamilton JP, Pose E, Graupera I, Ginès P, Solà E, Hernaez R. Global burden of disease: acute-on-chronic liver failure, a systematic review and meta-analysis. Gut 2022; 71:148-155. [PMID: 33436495 DOI: 10.1136/gutjnl-2020-322161] [Citation(s) in RCA: 87] [Impact Index Per Article: 43.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Revised: 12/22/2020] [Accepted: 12/23/2020] [Indexed: 12/16/2022]
Abstract
BACKGROUND AND AIMS Acute-on-chronic liver failure (ACLF) is characterised by acute decompensation of cirrhosis associated with organ failures. We systematically evaluated the geographical variations of ACLF across the world in terms of prevalence, mortality, aetiology of chronic liver disease (CLD), triggers and organ failures. METHODS We searched EMBASE and PubMed from 3/1/2013 to 7/3/2020 using the ACLF-EASL-CLIF (European Association for the Study of the Liver-Chronic Liver Failure) criteria. Two investigators independently conducted the abstract selection/abstraction of the aetiology of CLD, triggers, organ failures and prevalence/mortality by presence/grade of ACLF. We grouped countries into Europe, East/South Asia and North/South America. We calculated the pooled proportions, evaluated the methodological quality using the Newcastle-Ottawa Scale and statistical heterogeneity, and performed sensitivity analyses. RESULTS We identified 2369 studies; 30 cohort studies met our inclusion criteria (43 206 patients with ACLF and 140 835 without ACLF). The global prevalence of ACLF among patients admitted with decompensated cirrhosis was 35% (95% CI 33% to 38%), highest in South Asia at 65%. The global 90-day mortality was 58% (95% CI 51% to 64%), highest in South America at 73%. Alcohol was the most frequently reported aetiology of underlying CLD (45%, 95% CI 41 to 50). Infection was the most frequent trigger (35%) and kidney dysfunction the most common organ failure (49%). Sensitivity analyses showed regional estimates grossly unchanged for high-quality studies. Type of design, country health index, underlying CLD and triggers explained the variation in estimates. CONCLUSIONS The global prevalence and mortality of ACLF are high. Region-specific variations could be explained by the type of triggers/aetiology of CLD or grade. Health systems will need to tailor early recognition and treatment of ACLF based on region-specific data.
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Affiliation(s)
- Gabriel Mezzano
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain.,Gastroenterología - Hepatología, Hospital del Salvador. Universidad de Chile, Santiago, Chile
| | - Adria Juanola
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas (CIBERehd), Madrid, Spain
| | - Andres Cardenas
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas (CIBERehd), Madrid, Spain.,Institute of Digestive Disease and Metabolism, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain
| | - Esteban Mezey
- Division of Gastroenterology and Hepatology. Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - James P Hamilton
- Division of Gastroenterology and Hepatology. Department of Medicine, The Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Elisa Pose
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas (CIBERehd), Madrid, Spain
| | - Isabel Graupera
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas (CIBERehd), Madrid, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Pere Ginès
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas (CIBERehd), Madrid, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Elsa Solà
- Liver Unit, Hospital Clinic de Barcelona, Barcelona, Catalunya, Spain.,Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain.,Centro de Investigacion Biomedica en Red Enfermedades Hepaticas y Digestivas (CIBERehd), Madrid, Spain.,Faculty of Medicine and Health Sciences, University of Barcelona, Barcelona, Catalunya, Spain
| | - Ruben Hernaez
- Gastroenterology and Hepatology, Depatment of Medicine, Baylor College of Medicine, Houston, Texas, USA .,Section of Gastroenterology, Michael E DeBakey Veterans Affairs Medical Center, Houston, Texas, USA.,Center for Innovation in Quality, Effectiveness and Safety (IQuESt), Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
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17
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Jacques RDOC, Massignan LDS, Winkler MS, Balbinot RS, Balbinot SS, Soldera J. ACUTE-ON-CHRONIC LIVER FAILURE IS INDEPENDENTLY ASSOCIATED WITH LOWER SURVIVAL IN PATIENTS WITH SPONTANEOUS BACTERIAL PERITONITIS. ARQUIVOS DE GASTROENTEROLOGIA 2021; 58:344-352. [PMID: 34705969 DOI: 10.1590/s0004-2803.202100000-58] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/12/2021] [Indexed: 11/22/2022]
Abstract
BACKGROUND Spontaneous bacterial peritonitis (SBP) is a decompensation of cirrhosis with an in-hospital mortality ranging from 20% to 40%. OBJECTIVE The purpose of this study is to analyze if EASL-CLIF definition of acute-on-chronic liver failure (ACLF) is able to predict mortality in cirrhotic patients with SBP. METHODS Historical cohort study conducted in a public tertiary care teaching hospital. Data from medical records from January 2009 to July 2016 were obtained by searching the hospital electronic database for samples of ascites collected in the period. Electronic and physical medical records were analyzed and patients were included if they were over 18-years old, with cirrhosis and an ascites fluid compatible with SBP: 69 patients were included. Liver-specific scores were calculated and Kaplan-Meier survival analysis was used for univariate analysis and a stepwise approach to the Cox regression for multivariate analysis. RESULTS All cause mortality was 44%, 56.5% and 74% for 28-, 90- and 365-day, respectively. The prevalence of ACLF was 58%. Of these, 65% grade 1, 17.5% grade 2 and 17.5% grade 3. In multivariate analysis, the use of proton-pump inhi-bitors, alanine transaminase lower than 40 U/L, hemoglobin higher than 9 g/dL, absence of ACLF and lower CLIF-SOFA and MELD scores were independently associated with higher survival for both 28- and 90-day interval. CONCLUSION The presence of ACLF and higher CLIF-SOFA scores were independently associated with higher 28- and 90-day mortality in cirrhotic patients admitted due to SBP.
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Affiliation(s)
- Raquel de Oliveira Coberllini Jacques
- Hospital Geral, Medicina Interna, Caxias do Sul, RS, Brasil.,Universidade Federal de Santa Catarina, Departamento de Gastroenterologia, Florianópolis, SC, Brasil
| | - Lais da Silva Massignan
- Hospital Geral, Medicina Interna, Caxias do Sul, RS, Brasil.,Universidade Federal de Santa Catarina, Departamento de Gastroenterologia Clínica, Florianópolis, SC, Brasil
| | | | - Rafael Sartori Balbinot
- Universidade Federal de Ciências da Saúde de Porto Alegre, Medicina Interna, Porto Alegre, RS, Brasil
| | - Silvana Sartori Balbinot
- Universidade de Caxias do Sul, Departamento de Gastroenterologia Clínica, Caxias do Sul, RS, Brasil.,Universidade de São Paulo, Departamento de Gastroenterologia, São Paulo, SP, Brasil
| | - Jonathan Soldera
- Universidade de Caxias do Sul, Departamento de Gastroenterologia Clínica, Caxias do Sul, RS, Brasil.,Universidade Federal de Ciências da Saúde de Porto Alegre, Departamento de Hepatologia, Programa de Pós-Graduação em Medicina: Hepatologia, Porto Alegre, RS, Brasil
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18
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Comparison of General and Liver-Specific Prognostic Scores in Their Ability to Predict Mortality in Cirrhotic Patients Admitted to the Intensive Care Unit. Can J Gastroenterol Hepatol 2021; 2021:9953106. [PMID: 34608435 PMCID: PMC8487366 DOI: 10.1155/2021/9953106] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/31/2021] [Revised: 06/21/2021] [Accepted: 09/01/2021] [Indexed: 02/07/2023] Open
Abstract
INTRODUCTION Acute Physiology and Chronic Health Evaluation (APACHE) II and III and Sequential Organ Failure Assessment (SOFA) are prognostic scores commonly used in the intensive care unit (ICU). Their accuracy in predicting mortality has not been adequately evaluated in comparison to prognostic scores commonly used in critically ill cirrhotic patients with acute decompensation (AD) or acute-on-chronic liver failure (ACLF). AIMS This study was conducted to evaluate the performance of prognostic scores, including APACHE II, SOFA, Chronic Liver Failure Consortium (CLIF-C) SOFA, Child-Turcotte-Pugh (CPS), Model for End-Stage Liver Disease (MELD), MELD-Na, MELD to serum sodium ratio (MESO) index, CLIF-C organ failure (CLIF-C OF), CLIF-C ACLF, and CLIF-C AD scores, in predicting mortality of cirrhotic patients admitted to the ICU. Patients and Methods. A total of 382 patients (280 males, mean age 67.3 ± 10.6 years) with cirrhosis were retrospectively evaluated. All prognostic scores were calculated in the first 24 hours of ICU admission. Their ability to predict mortality was measured using the analysis of the area under the receiver operating characteristic curve (AUC). RESULTS Mortality was observed in 31% of the patients. Analysis of AUC revealed that CLIF-C OF (0.807) and CLIF-SOFA (0.776) had the best ability to predict mortality in all patients, but CLIF-C OF (0.749) had higher prognostic accuracy in patients with ACLF. CLIF-SOFA, SOFA, and CLIF-C AD had the highest AUC values in patients with AD, with no statistical difference (p=0.971). CONCLUSIONS When compared to other general or liver-specific prognostic scores, CLIF-C OF, CLIF-SOFA, SOFA, and CLIF-C AD have good accuracy to predict mortality in critically ill patients with cirrhosis and patients with AD. According to the clinical scenario, different scores should be used to provide prognosis to patients with cirrhosis in the ICU.
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19
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Morais Rateke EC, Matiollo C, de Andrade Moura EQ, Andrigueti M, Maccali C, Fonseca JS, Canova SMF, Narciso-Schiavon JL, Schiavon LL. Low sodium to potassium ratio in spot urine sample is associated with progression to acute kidney injury and mortality in hospitalized patients with cirrhosis. Dig Liver Dis 2021; 53:1159-1166. [PMID: 33446446 DOI: 10.1016/j.dld.2020.12.117] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/02/2020] [Revised: 12/04/2020] [Accepted: 12/23/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND sodium to potassium ratio in spot urine sample (Na/Kur) is a surrogate marker of sodium excretion that is recommended for the management of patients with ascites due to cirrhosis. AIMS to investigate Na/Kur ratio and fractional excretion of sodium (FENa) in patients admitted with decompensated cirrhosis, evaluating its relationship with acute kidney injury (AKI) and prognosis. METHODS prospective cohort study included 225 adult subjects. Urine samples were obtained within 48 h of hospitalization. RESULTS AKI at admission was observed in 32.9% of patients and was associated with lower Na/Kur ratio, but not FENa. Among 151 subjects initially without kidney dysfunction, AKI at some point during hospitalization occurred in 26.2% and was independently associated with low Na/Kur ratio at admission. AKI was observed in 44% of the patients with Na/Kur ratio < 1 and only in 8% when values ≥ 2. Na/Kur ratio at admission was independently associated with 30-day mortality, with Kaplan-Meier survival probability of 78.8% for Na/Kur ratio < 1 and 93.6% for values ≥ 1. CONCLUSIONS low Na/Kur ratio in spot urine sample is associated with progression to AKI and lower short-term survival in patients hospitalized for decompensated cirrhosis.
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Affiliation(s)
| | - Camila Matiollo
- Unidade de Laboratório de Análises Clínicas, Hospital Universitário, Universidade Federal de Santa Catarina, Brazil
| | | | - Michelle Andrigueti
- Unidade de Laboratório de Análises Clínicas, Hospital Universitário, Universidade Federal de Santa Catarina, Brazil
| | - Claudia Maccali
- Serviço de Gastroenterologia, Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
| | - Janaína Sant'Ana Fonseca
- Serviço de Gastroenterologia, Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
| | | | - Janaína Luz Narciso-Schiavon
- Serviço de Gastroenterologia, Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil
| | - Leonardo Lucca Schiavon
- Serviço de Gastroenterologia, Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brasil.
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20
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Durand F, Roux O, Weiss E, Francoz C. Acute-on-chronic liver failure: Where do we stand? Liver Int 2021; 41 Suppl 1:128-136. [PMID: 34155793 DOI: 10.1111/liv.14855] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 02/19/2021] [Indexed: 12/12/2022]
Abstract
Acute-on-chronic liver failure (ACLF) is defined by the rapid development of organ(s) failure(s) associated with high rates of early (28-day) mortality in patients with cirrhosis. ACLF has been categorized into three grades of increasing severity according to the nature and number of organ failures. In patients with grade 3 ACLF, 28-day mortality is >70%. While the definition of ACLF has been endorsed by European scientific societies, North American and Asian Pacific associations have proposed alternative definitions. A prognostic score called the CLIF-C ACLF score provides a more precise assessment of the prognosis of patients with ACLF. Although bacterial infections and variceal bleeding are common precipitating factors, no precipitating factor can be identified in almost 60% of patients with ACLF. There is increasing evidence that cirrhosis is a condition characterized by a systemic inflammatory state and occult infections or translocation of bacteria or bacterial products from the lumen of the GUT to the systemic circulation which could play a role in the development of ACLF. Simple and readily available variables to predict the occurrence of ACLF in patients with cirrhosis have been identified and high-risk patients need careful management. Whether prolonged administration of statins, rifaximin or albumin can prevent ACLF requires further study. Patients with organ(s) failure(s) may needed to be admitted to the ICU and there should be no hesitation in admitting patients with cirrhosis to the ICU. No benefit to survival was observed with albumin dialysis and rescue transplantation is the best option in the most severe patients. One-year post-transplant survival rates exceeding 70%-75% have been reported, including in patients with grade 3 ACLF but these patients were highly selected. Criteria have been proposed to define futile transplantation (too ill to be transplanted), but these criteria need to be refined to include age, comorbidities and frailty in addition to markers of disease severity.
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Affiliation(s)
- François Durand
- Hepatology & Liver Intensive Care Hospital Beaujon, Clichy, France.,INSERM U1149, Clichy, France.,University of Paris, Clichy, France
| | - Olivier Roux
- Hepatology & Liver Intensive Care Hospital Beaujon, Clichy, France
| | - Emmanuel Weiss
- INSERM U1149, Clichy, France.,Anesthesiology and Intensive Care, Clichy, France
| | - Claire Francoz
- Hepatology & Liver Intensive Care Hospital Beaujon, Clichy, France.,INSERM U1149, Clichy, France
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Balcar L, Semmler G, Pomej K, Simbrunner B, Bauer D, Hartl L, Jachs M, Paternostro R, Bucsics T, Pinter M, Trauner M, Mandorfer M, Reiberger T, Scheiner B. Patterns of acute decompensation in hospitalized patients with cirrhosis and course of acute-on-chronic liver failure. United European Gastroenterol J 2021; 9:427-437. [PMID: 34050619 PMCID: PMC8259248 DOI: 10.1002/ueg2.12089] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2020] [Accepted: 03/22/2021] [Indexed: 12/11/2022] Open
Abstract
INTRODUCTION Recently, based on data from the PREDICT study, the European Foundation for the Study of Chronic Liver Failure (EF-CLIF) consortium proposed pathophysiological/prognostic groups in hospitalized patients with cirrhosis: stable decompensated cirrhosis (SDC), unstable decompensated cirrhosis (UDC), pre-acute-on-chronic liver failure (pre-ACLF), and ACLF. We evaluated the outcomes of these subgroups in a real-life cohort of hospitalized patients with cirrhosis. METHODS Patients with cirrhosis developing first AD between 09/2010 and 12/2017 at the Vienna General Hospital were evaluated for this retrospective analysis. RESULTS Two hundred and ten patients with cirrhosis (aged 57.6 ± 11.8 years) including n = 45 (21.4%) SDC, n = 100 (47.6%) UDC, n = 28 (13.3%) pre-ACLF, and n = 37 (17.6%) with ACLF were considered. The proposed AD subgroups discriminated between patients with favorable (1-year mortality: SDC: 6.7% and UDC: 19.6%) and dismal prognosis (90-day mortality: pre-ACLF: 42.9%). Interestingly, systemic inflammation gradually increased (e.g., C-reactive protein, SDC: 0.9 mg/dl, vs. UDC: 2.0 mg/dl vs. pre-ACLF: 3.2 mg/dl, p < 0.001) while renal function was progressively deteriorating (creatinine levels, SDC: 0.8 mg/dl vs. UDC: 0.9 mg/dl vs. pre-ACLF: 1.2 mg/dl, p < 0.001) across prognostic subgroups in patients with cirrhosis. DISCUSSION The recently proposed pathophysiological/prognostic EF-CLIF subgroups are also reproduceable in a real-life cohort of cirrhotic patients. As ACLF is a common and important complication, patients at risk of pre-ACLF at index AD should be evaluated and if disease proceeds, been treated early and aggressively to avoid excessive mortality.
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Affiliation(s)
- Lorenz Balcar
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Katharina Pomej
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria.,Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - David Bauer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Lukas Hartl
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Mathias Jachs
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Theresa Bucsics
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria.,Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Bernhard Scheiner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria
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22
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Systemic Inflammatory Response Syndrome in Patients Hospitalized for Acute Decompensation of Cirrhosis. Can J Gastroenterol Hepatol 2021; 2021:5581587. [PMID: 33987144 PMCID: PMC8093053 DOI: 10.1155/2021/5581587] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/02/2021] [Revised: 04/09/2021] [Accepted: 04/13/2021] [Indexed: 12/29/2022] Open
Abstract
BACKGROUND Although recently challenged, systemic inflammatory response syndrome (SIRS) criteria are still commonly used in daily practice to define sepsis. However, several factors in liver cirrhosis may negatively impact its prognostic ability. Goals. To investigate the factors associated with the presence of SIRS, the characteristics of SIRS related to infection, and its prognostic value among patients hospitalized for acute decompensation of cirrhosis. Study. In this cohort study from two tertiary hospitals, 543 patients were followed up, up to 90 days. Data collection, including the prognostic models, was within 48 hours of admission. RESULTS SIRS was present in 42.7% of the sample and was independently associated with upper gastrointestinal bleeding (UGB), ACLF, infection, and negatively related to beta-blockers. SIRS was associated with mortality in univariate analysis, but not in multiple Cox regression analysis. The Kaplan-Meier survival probability of patients without SIRS was 73.0% and for those with SIRS was 64.7%. The presence of SIRS was not significantly associated with mortality when considering patients with or without infection, separately. Infection in SIRS patients was independently associated with Child-Pugh C and inversely related to UGB. Among subjects with SIRS, mortality was independently related to the presence of infection, ACLF, and Child-Pugh C. CONCLUSIONS SIRS was common in hospitalized patients with cirrhosis and was of no prognostic value, even in the presence of infection.
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23
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Satapathy SK, Roth NC, Kvasnovsky C, Hirsch JS, Trindade AJ, Molmenti E, Barish M, Hirschwerk D, Da BL, Bernstein D. Risk factors and outcomes for acute-on-chronic liver failure in COVID-19: a large multi-center observational cohort study. Hepatol Int 2021; 15:766-779. [PMID: 33826042 PMCID: PMC8024443 DOI: 10.1007/s12072-021-10181-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 03/14/2021] [Indexed: 02/06/2023]
Abstract
Objective Coronavirus disease 2019 [COVID-19] infection in patients with chronic liver disease [CLD] may precipitate acute-on-chronic liver failure [ACLF]. In a large multi-center cohort of COVID-19-infected patients, we aim to analyze (1) the outcomes of patients with underlying CLD [with and without cirrhosis] and (2) the development and impact of ACLF on in-hospital mortality. Design We identified 192 adults with CLD from among 10,859 patients with confirmed COVID-19 infection (admitted to any of 12 hospitals in a New York health care system between March 1, 2020 and April 27, 2020). ACLF was defined using the EASL-CLIF Consortium definition. Patient follow-up was through April 30, 2020, or until the date of discharge, transfer, or death. Results Of the 84 patients with cirrhosis, 32 [38%] developed ACLF, with respiratory failure [39%] and renal failure [26%] being the most common. Hispanic/Latino ethnicity was particularly at higher risk of in-hospital mortality [adjusted HR 4.92, 95% 1.27–19.09, p < 0.02] in cirrhosis despite having lower risk of development of ACLF [HR 0.26, 95% CI 0.08–0.89, p = 0.03]. Hypertension on admission predicted development of ACLF [HR 3.46, 95% CI 1.12–10.75, p = 0.03]. In-hospital mortality was not different between CLD patients with or without cirrhosis [p = 0.24] but was higher in those with cirrhosis who developed ACLF [adjusted HR 9.06, 95% CI 2.63–31.12, p < 0.001] with a trend for increased mortality by grade of ACLF [p = 0.002]. There was no difference in in-hospital mortality between the CLD cohort compared to matched control without CLD (log rank, p = 0.98) and between the cirrhosis cohort compared to matched control without cirrhosis (log rank, p = 0.51). Conclusion Development of ACLF is the main driver of increased in-hospital mortality in hospitalized patients with COVID-19 infection and cirrhosis. Supplementary Information The online version contains supplementary material available at 10.1007/s12072-021-10181-y.
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Affiliation(s)
- Sanjaya K Satapathy
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra Blvd, Hempstead, NY, 11549, USA. .,Division of Hepatology at Sandra Atlas Bass Center for Liver Diseases and Transplantation, Barbara and Zucker School of Medicine/Northwell Health, 400 Community Drive, Manhasset, NY, 11030, USA.
| | - Nitzan C Roth
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra Blvd, Hempstead, NY, 11549, USA
| | - Charlotte Kvasnovsky
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra Blvd, Hempstead, NY, 11549, USA
| | - Jamie S Hirsch
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra Blvd, Hempstead, NY, 11549, USA.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr, Manhasset, NY, 11030, USA.,Department of Information Services, Northwell Health, New Hyde Park, NY, USA
| | - Arvind J Trindade
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra Blvd, Hempstead, NY, 11549, USA
| | - Ernesto Molmenti
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra Blvd, Hempstead, NY, 11549, USA.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr, Manhasset, NY, 11030, USA
| | - Matthew Barish
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra Blvd, Hempstead, NY, 11549, USA.,Radiology Informatics, Imaging Service Line, North Shore University Hospital, Northwell Health, 300 Community Dr, Manhasset, NY, 11030, USA.,Institute of Health Innovations and Outcomes Research, Feinstein Institutes for Medical Research, Northwell Health, 350 Community Dr, Manhasset, NY, 11030, USA
| | - David Hirschwerk
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra Blvd, Hempstead, NY, 11549, USA
| | - Ben L Da
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra Blvd, Hempstead, NY, 11549, USA
| | - David Bernstein
- Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, Northwell Health, 500 Hofstra Blvd, Hempstead, NY, 11549, USA
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24
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Terres AZ, Balbinot RS, Muscope ALF, Longen ML, Schena B, Cini BT, Luis Rost G, Balensiefer JIL, Eberhardt LZ, Balbinot RA, Balbinot SS, Soldera J. Evidence-based protocol for diagnosis and treatment of hepatorenal syndrome is independently associated with lower mortality. GASTROENTEROLOGIA Y HEPATOLOGIA 2021; 45:25-39. [PMID: 33746028 DOI: 10.1016/j.gastrohep.2021.02.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 01/22/2021] [Accepted: 02/05/2021] [Indexed: 02/07/2023]
Abstract
BACKGROUND Hepatorenal syndrome (HRS) is the deadliest complication of cirrhosis. The purpose of this study is to analyze if the use of a protocol for HRS is associated with higher survival in these patients. METHODS An evidence-based protocol for the diagnosis and treatment of HRS was instituted in 2013. Data from medical records from 2010 to 2016 were obtained by searching the hospital database for patients who received terlipressin, in the three years before and after the institution of the protocol. Data were reviewed to confirm the diagnosis of HRS and multiple variables were collected. Liver-specific scores were calculated and a stepwise Cox regression approach was used for univariate and multivariate analysis. RESULTS The study included 46 patients, 20 from the pre-protocol period and 26 from the post-protocol period. Respectively, mortality at 30 days, 90 days and 365 days was 75%, 75% and 90% for the pre-protocol period, and 61%, 69% and 80% for the post-protocol period. In the multivariate analysis, an aspartate aminotransferase (AST) of <40U/L, the pre-protocol period and higher Child-Turcotte-Pugh scores were associated with higher 30-day and 90-day mortality. The total mean dose of terlipressin and human albumin used per patient was reduced from 27mg to 22mg and from 236g to 144g, respectively, after the institution of the protocol. This was not associated with higher mortality. CONCLUSION The use of an evidence-based protocol for the treatment of HRS translated into a higher survival. The authors suggest that the use of evidence-based protocols for the diagnosis and treatment of HRS could reduce cost and mortality in tertiary hospitals.
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Affiliation(s)
- Alana Zulian Terres
- Internal Medicine, Hospital Pompeia, Caxias do Sul, RS, Brazil; Gastroenterology, Hospital Geral de Caxias do Sul (RS), Brazil
| | - Rafael Sartori Balbinot
- Residency in Internal Medicine, Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil; Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
| | | | | | - Bruna Schena
- Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
| | - Bruna Teston Cini
- Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
| | - Gilberto Luis Rost
- Faculty of Medicine, Universidade de Caxias do Sul, Caxias do Sul, RS, Brazil
| | | | | | - Raul Angelo Balbinot
- Clinical Gastroenterology, Universidade de Caxias do Sul (UCS), Caxias do Sul, RS, Brazil; Department of Gastroenterology, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Silvana Sartori Balbinot
- Clinical Gastroenterology, Universidade de Caxias do Sul (UCS), Caxias do Sul, RS, Brazil; Department of Gastroenterology, Universidade de São Paulo (USP), São Paulo, SP, Brazil
| | - Jonathan Soldera
- Clinical Gastroenterology, Universidade de Caxias do Sul (UCS), Caxias do Sul, RS, Brazil; Universidade Federal de Ciências da Saúde de Porto Alegre (UFCSPA), Porto Alegre, RS, Brazil.
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25
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Liu LX, Zhang Y, Nie Y, Zhu X. Assessing the Prediction Effect of Various Prognosis Model for 28-Day Mortality in Acute-on-Chronic Liver Failure Patients. Risk Manag Healthc Policy 2021; 13:3155-3163. [PMID: 33402854 PMCID: PMC7778450 DOI: 10.2147/rmhp.s281999] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2020] [Accepted: 12/10/2020] [Indexed: 12/13/2022] Open
Abstract
Background Acute-on-chronic liver failure (ACLF) is an extremely clinical entity associated with short-term high mortality. The CLIF-SOFA score measures both hepatic and extrahepatic organ dysfunction and can discriminate significantly better between survivors and nonsurvivors compared to other methods. The MELD score is widely used for organ allocation in liver transplantation. Recent reports indicate that the PWR is a potential biomarker for predicting clinical outcomes. The ALBI score is a new score model for evaluating the severity of liver dysfunction. We aimed to compare these prognosis models to predict short-term mortality in ACLF patients. Methods A retrospective analysis of 89 ACLF patients between 2015 and 2018 was performed. The receiver operating characteristic (ROC) curve was used to assess the power of four prognosis models for predicting 28-day mortality in patients with ACLF. Results The ALBI score, MELD score and CLIF-SOFA score were significantly higher, and the PWR was slightly lower in nonsurviving ACLF patients than in surviving patients. The MELD score and ALBI score were positively correlated with the CLIF-SOFA score, while the PWR was inversely related to the CLIF-SOFA score. The area under the ROC curves (AUROCS) of the CLIF-SOFA score, PWR, ALBI score and MELD score were 0.804, 0.759, 0.710 and 0.670, respectively. Conclusion The CLIF-SOFA score, PWR and ALBI score can better predict 28-day mortality in ACLF patients, but the MELD score has worse predictability. The CLIF-SOFA score is the best prognosis model among these models. PWR may be a simple and useful tool that can predict 28-day outcome.
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Affiliation(s)
- Lin Xiang Liu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, People's Republic of China
| | - Yue Zhang
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, People's Republic of China
| | - Yuan Nie
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, People's Republic of China
| | - Xuan Zhu
- Department of Gastroenterology, The First Affiliated Hospital of Nanchang University, Nanchang 330006, People's Republic of China
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26
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Philips CA, Ahamed R, Rajesh S, George T, Mohanan M, Augustine P. Update on diagnosis and management of sepsis in cirrhosis: Current advances. World J Hepatol 2020; 12:451-474. [PMID: 32952873 PMCID: PMC7475781 DOI: 10.4254/wjh.v12.i8.451] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2020] [Revised: 05/28/2020] [Accepted: 06/27/2020] [Indexed: 02/06/2023] Open
Abstract
Sepsis and septic shock are catastrophic disease entities that portend high mortality in patients with cirrhosis. In cirrhosis, hemodynamic perturbations, immune dysregulation, and persistent systemic inflammation with altered gut microbiota in the background of portal hypertension enhance the risk of infections and resistance to antimicrobials. Patients with cirrhosis develop recurrent life-threatening infections that progress to multiple organ failure. The definition, pathophysiology, and treatment options for sepsis have been ever evolving. In this exhaustive review, we discuss novel advances in the understanding of sepsis, describe current and future biomarkers and scoring systems for sepsis, and delineate newer modalities and adjuvant therapies for the treatment of sepsis from existing literature to extrapolate the same concerning the management of sepsis in cirrhosis. We also provide insights into the role of gut microbiota in initiation and progression of sepsis and finally, propose a treatment algorithm for management of sepsis in patients with cirrhosis.
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Affiliation(s)
- Cyriac Abby Philips
- The Liver Unit and Monarch Liver Lab, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Rizwan Ahamed
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Sasidharan Rajesh
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Tom George
- Division of Hepatobiliary Interventional Radiology, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Meera Mohanan
- Anaesthesia and Critical Care, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
| | - Philip Augustine
- Gastroenterology and Advanced G.I Endoscopy, Cochin Gastroenterology Group, Ernakulam Medical Center, Kochi 682028, Kerala, India
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27
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Mahmud N, Sundaram V, Kaplan DE, Taddei TH, Goldberg DS. Grade 1 Acute on Chronic Liver Failure Is a Predictor for Subsequent Grade 3 Failure. Hepatology 2020; 72:230-239. [PMID: 31677284 PMCID: PMC7195222 DOI: 10.1002/hep.31012] [Citation(s) in RCA: 31] [Impact Index Per Article: 7.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2019] [Accepted: 10/08/2019] [Indexed: 02/06/2023]
Abstract
BACKGROUND AND AIMS Acute on chronic liver failure (ACLF) results in extremely high short-term mortality in patients with underlying cirrhosis. The European Association for the Study of the Liver criteria grade ACLF severity from 1 (least severe) to 3 (most severe) based on organ failures (OFs) that develop after an acute decompensation (AD). However, the implications of surviving low-grade ACLF in terms of risk of subsequent high-grade ACLF are unclear. APPROACH AND RESULTS We conducted a retrospective cohort study of patients with compensated cirrhosis in the Veterans Health Administration database from January 2008 to June 2016. Propensity matching for grade 1 (G1) ACLF, followed by Cox regression, was used to model risk of subsequent grade 3 (G3) ACLF. Stratified analyses of different ADs and OFs were also performed. We identified 4,878 patients with well-matched propensity scores. G1 ACLF events conferred a significantly increased risk of subsequent G3 ACLF relative no previous G1 ACLF (hazard ratio, 8.69; P < 0.001). When stratified by AD, patients with ascites or hepatic encephalopathy were significantly more likely to develop G3 ACLF relative to those with gastrointestinal bleed or infection as an AD (P < 0.001). Risk of G3 ACLF also varied significantly by type of OF characterizing previous G1 ACLF, with liver, coagulation, and circulatory failure posing the highest increased risk. CONCLUSIONS Patients who recover from G1 ACLF have substantially increased risk of later developing G3 ACLF as compared to those who never have G1 ACLF. Moreover, reversible decompensations for G1 ACLF have a lower risk of G3 ACLF, and liver-intrinsic OFs confer a much higher risk of G3 ACLF. These findings have implications for prognosis, future surveillance, and triaging early transplant evaluation.
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Affiliation(s)
- Nadim Mahmud
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Vinay Sundaram
- Division of Gastroenterology and Comprehensive Transplant Center, Cedars-Sinai Medical Center, Los Angeles, CA
| | - David E. Kaplan
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Department of Medicine, Corporal Michael J. Crescenz VA Medical Center, Philadelphia, PA
| | - Tamar H. Taddei
- Division of Digestive Diseases, Yale University School of Medicine, New Haven, CT,VA Connecticut Healthcare System, West Haven, CT
| | - David S. Goldberg
- Division of Gastroenterology, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA,Division of Digestive Health and Liver Diseases, Department of Medicine, University of Miami Miller School of Medicine, Miami, FL
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28
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Matiollo C, Rateke ECDM, de Oliveira KG, Turnes BL, da Silva TE, Maccali C, Latini AS, Narciso-Schiavon JL, Schiavon LL. Elevated neopterin levels are associated with acute-on-chronic liver failure and mortality in patients with liver cirrhosis. Dig Liver Dis 2020; 52:753-760. [PMID: 32434738 DOI: 10.1016/j.dld.2020.03.024] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Revised: 03/09/2020] [Accepted: 03/26/2020] [Indexed: 12/11/2022]
Abstract
BACKGROUND Macrophage activation plays a central role in hepatic and systemic inflammation and is involved in the pathogenesis of acute-on-chronic liver failure (ACLF). AIMS This study aimed to investigate neopterin levels in patients admitted for acute decompensation (AD) of cirrhosis, evaluating its relationship with ACLF and prognosis. METHODS This prospective cohort study included 205 adult subjects hospitalized for AD of cirrhosis. Twenty-one healthy subjects and 89 patients with stable cirrhosis were evaluated as controls. RESULTS Circulating neopterin was higher in AD as compared to stable cirrhosis and healthy controls (p<0.001). ACLF was independently associated with higher neopterin levels (OR 1.015, 95% CI 1.002-1.028, p = 0.025). In the multivariate Cox regression analysis, neopterin levels (HR = 1.002, IC 95% 1.000-1.004, p = 0.041), Child-Pugh class C, and ACLF were predictors of 30-day survival. Among patients with ACLF, the Kaplan-Meier survival probability was 71.4% in those with neopterin levels < 25 nmol/L and 31.0% if neopterin ≥ 25 nmol/L (p<0.001). CONCLUSIONS Higher circulating neopterin was associated with ACLF in patients hospitalized for AD of cirrhosis. Neopterin levels were also independently predictors of high short-term mortality, especially among patients with ACLF, and could represent a useful biomarker of macrophage activation in clinical practice.
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Affiliation(s)
- Camila Matiollo
- Laboratório de Análises Clínicas, Hospital Universitário, Universidade Federal de Santa Catarina, Brazil
| | | | - Karina Ghisoni de Oliveira
- Laboratório de Bioenergética e Estresse Oxidativo - LABOX, Universidade Federal de Santa Catarina, Brazil
| | - Bruna Lenfers Turnes
- Laboratório de Bioenergética e Estresse Oxidativo - LABOX, Universidade Federal de Santa Catarina, Brazil
| | - Telma Erotides da Silva
- Serviço de Gastroenterologia, Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Claudia Maccali
- Serviço de Gastroenterologia, Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - Alexandra Susana Latini
- Laboratório de Bioenergética e Estresse Oxidativo - LABOX, Universidade Federal de Santa Catarina, Brazil
| | - Janaína Luz Narciso-Schiavon
- Serviço de Gastroenterologia, Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil
| | - L L Schiavon
- Serviço de Gastroenterologia, Hospital Universitário, Universidade Federal de Santa Catarina, Florianópolis, SC, Brazil.
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Abstract
To analyze the impact of acute-on-chronic liver failure (ACLF) immediately before liver transplantation (LT) on short-term kidney function.
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Leão GS, Lunardi FL, Picon RV, Tovo CV, de Mattos AA, de Mattos ÂZ. Acute-on-chronic liver failure: A comparison of three different diagnostic criteria. Ann Hepatol 2020; 18:373-378. [PMID: 31053547 DOI: 10.1016/j.aohep.2019.01.001] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/14/2018] [Revised: 12/28/2018] [Accepted: 01/09/2019] [Indexed: 02/07/2023]
Abstract
INTRODUCTION AND AIM Different criteria are applied for the diagnosis of acute-on-chronic liver failure (ACLF). Our aim was to compare the performance of different ACLF diagnostic criteria for predicting mortality. MATERIALS AND METHODS This was a prospective cohort study of adult cirrhotic patients admitted to a tertiary hospital for acute decompensation (AD) of cirrhosis. The evaluated outcome was mortality at 28 and 90 days, according to the different ACLF diagnostic criteria: Chronic Liver Failure Consortium (CLIF-C), Asian Pacific Association for the Study of the Liver-ACLF Research Consortium (AARC) and North American Consortium for the Study of End-Stage Liver Disease (NACSELD). Prognostic performance was evaluated using receiver operating characteristic (ROC) curves. RESULTS 146 patients were included. 43 (29.5%) with ACLF according to CLIF-C definition, 14 (9.6%) with ACLF by AARC definition, and 6 (4.1%) by NACSELD definition. According to Kaplan-Meier survival analyses median survival of patients with ACLF by CLIF-C definition was 27.0 days, median survival of patients with ACLF by AARC definition was 27.0 days, and median survival of patients with ACLF by NACSELD definition was 4.0 days. The areas under the ROC curves for performance evaluation in predicting mortality at 28 days for CLIF-C, AARC and NACSELD criteria were, respectively, 0.710, 0.560 and 0.561 (p=0.002). Regarding 90-day mortality, the areas under the ROC curves were 0.760, 0.554 and 0.555 respectively (p<0.001). CONCLUSION ACLF definition proposed by CLIF-C had better performance in predicting mortality at 28 and 90 days when compared to criteria proposed by AARC and NACSELD.
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Affiliation(s)
- Gabriel S Leão
- Federal University of Health Sciences of Porto Alegre, Graduate Program in Medicine: Hepatology, Porto Alegre, Brazil; Mãe de Deus Hospital, Gastroenterology and Hepatology Unit, Porto Alegre, Brazil
| | - Felipe L Lunardi
- Mãe de Deus Hospital, Gastroenterology and Hepatology Unit, Porto Alegre, Brazil
| | | | - Cristiane V Tovo
- Federal University of Health Sciences of Porto Alegre, Graduate Program in Medicine: Hepatology, Porto Alegre, Brazil; Nossa Senhora da Conceição Hospital, Gastroenterology and Hepatology Unit, Porto Alegre, Brazil
| | - Angelo A de Mattos
- Federal University of Health Sciences of Porto Alegre, Graduate Program in Medicine: Hepatology, Porto Alegre, Brazil
| | - Ângelo Z de Mattos
- Federal University of Health Sciences of Porto Alegre, Graduate Program in Medicine: Hepatology, Porto Alegre, Brazil.
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Maggi DC, Borgonovo A, Bansho ET, Soares-Silva PE, Silva TE, Colombo BS, Wildner LM, Bazzo ML, Dantas-Correa EB, Narciso-Schiavon JL, Schiavon LL. Serial assessment of hepatic encephalopathy in patients hospitalised for acute decompensation of cirrhosis. Ann Hepatol 2020; 18:331-337. [PMID: 31053543 DOI: 10.1016/j.aohep.2018.11.002] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 10/22/2018] [Accepted: 11/23/2018] [Indexed: 02/08/2023]
Abstract
INTRODUCTION AND AIM Hepatic encephalopathy (HE) is a frequent complication of cirrhosis, but the clinical and prognostic significance of the progression of mental status in hospitalised cirrhotics is unknown. We aimed to investigate the prognostic significance of serial evaluation of HE in patients hospitalised for acute decompensation (AD) of cirrhosis. MATERIALS AND METHODS Patients (n=293) were evaluated for HE (West-Haven criteria) at admission and at day-3 and classified in two groups: (1) Absent or improved HE: HE absent at admission and at day-3, or any improvement at day-3; (2) Unfavourable progression: Development of HE or HE present at admission and stable/worse at day-3. RESULTS Unfavourable progression of HE was observed in 31% of patients and it was independently associated with previous HE, Child-Pugh C and acute-on-chronic liver failure (ACLF). MELD score and unfavourable progression of HE were independently associated with 90-day mortality. The 90-day Kaplan-Meier survival probability was 91% in patients with MELD<18 and absent or improved HE and only 31% in subjects with both MELD≥18 and unfavourable progression of HE. Unfavourable progression of HE was also related to lower survival in patients with or without ACLF. Worsening of GCS at day-3 was observed in 11% of the sample and was related with significantly high mortality (69% vs. 27%, P<0.001). CONCLUSION Among cirrhotics hospitalised for AD, unfavourable progression of HE was associated with high short-term mortality and therefore can be used for prognostication and to individualise clinical care.
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Affiliation(s)
- Dariana C Maggi
- Division of Gastroenterology, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Ariane Borgonovo
- Division of Gastroenterology, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Emília T Bansho
- Division of Gastroenterology, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Pedro E Soares-Silva
- Division of Gastroenterology, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Telma E Silva
- Division of Gastroenterology, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Bruno S Colombo
- Division of Gastroenterology, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Letícia M Wildner
- Department of Clinical Analysis, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Maria L Bazzo
- Department of Clinical Analysis, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | - Esther B Dantas-Correa
- Division of Gastroenterology, Federal University of Santa Catarina, Florianópolis, SC, Brazil
| | | | - Leonardo L Schiavon
- Division of Gastroenterology, Federal University of Santa Catarina, Florianópolis, SC, Brazil.
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Outcomes of Liver Transplant Recipients With Acute-on-Chronic Liver Failure Based on EASL-CLIF Consortium Definition: A Single-center Study. Transplant Direct 2020; 6:e544. [PMID: 32309630 PMCID: PMC7145003 DOI: 10.1097/txd.0000000000000984] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Accepted: 01/15/2020] [Indexed: 12/22/2022] Open
Abstract
The impact of acute-on-chronic liver failure (ACLF) defined by European Association for the Study of the Liver-Chronic Liver Failure in liver transplant (LT) recipients has not been well characterized. The aim of the study was to assess early posttransplant morbidity and survival of ACLF patients. Methods Eight hundred twenty-five consecutive LT patients (04/2006-03/2013) were included in a retrospective analysis. Of the 690 evaluable patients, 589 had no ACLF, and the remaining 101 were grouped into ACLF Grades 1-3 (ACLF Grade 1: 50 [49.5%], ACLF Grade 2: 32 [31.7%], and ACLF Grade 3: 19 [18.8%]). Results LT recipients transplanted in the context of ACLF had significantly increased serum creatinine (2.27 ± 1.16 versus 0.98 ± 0.32; P < 0.0001), and inferior 1-year graft (90% versus 78%; P < 0.0001) and patient survival (92% versus 82%; P = 0.0004) by Kaplan-Meier survival analysis; graft and patient survival correlated negatively with increasing severity of ACLF. One-year graft and patient survival were lower in those with high ACLF (Grade 2 and 3) irrespective of Model for End-Stage Liver Disease compared with other groups. The ACLF group had longer intensive care unit stays (10.6 ± 19.5 versus 4.2 ± 9; P < 0.0001), hospital stays (20.9 ± 25.9 versus 11.7 ± 11.4; P < 0.0001), and increased surgical re-exploration (26.7 % versus 14.6%, P = 0.002). Conclusions Patients with ACLF undergoing LT have significantly higher resource utilization, inferior graft survival and patient survival, and renal dysfunction at 1 year. The combination of ACLF and Model for End-Stage Liver Disease can be considered when determining the suitability for potential transplantation.
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Predictive value of the Chinese group on the study of severe hepatitis B-acute-on-chronic liver failure score in the short-term prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure. Chin Med J (Engl) 2020; 132:1541-1549. [PMID: 31188162 PMCID: PMC6616238 DOI: 10.1097/cm9.0000000000000298] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Background: As a large, prospective, multicenter study-based prognostic score for hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF), the Chinese group on the study of severe hepatitis B-acute-on-chronic liver failure score (COSSH-ACLFs), has been approved by some foreign scholars; however, its predictive value needs to be verified. This study investigated the predictive value of COSSH-ACLFs for short-term prognosis in Chinese patients with HBV-ACLF. Methods: This retrospective cohort study included 751 patients with HBV-ACLF admitted to the Fifth Medical Center of Chinese PLA General Hospital between January 2011 and December 2014. Spearman method was used to assess the correlation of COSSH-ACLFs with classical scores. Different COX multivariate regression models were used to confirm the relationship between COSSH-ACLFs and short-term prognosis in patients with HBV-ACLF, and stratified analysis was used to further verify the stability of this relationship. We compared the predictive powers of COSSH-ACLFs and other classical scores using area under the receiver operating characteristic curve (AUROC) and Z-test. Results: A total of 975 patients with HBV-ACLF were screened, and 751 were analyzed (623 male and 128 female). COSSH-ACLFs was the highest in patients with end-stage ACLF, followed by those with middle- and early-stage ACLF (H = 211.8, P < 0.001). In the fully adjusted model, COX multivariate regression analysis revealed that COSSH-ACLFs (as a continuous variable) was independently and positively correlated with mortality risk in patients with HBV-ACLF at 28 days (hazard ratio [HR]: 1.37 [1.22, 1.53], P < 0.001) and 90 days (HR: 1.43 [1.29, 1.58], P < 0.001). The same trend could be observed in the crude model and minimally adjusted model. The AUROCs of COSSH-ACLFs for 28-day and 90-day prognoses in patients with HBV-ACLF were 0.807 and 0.792, respectively, indicating a stronger predictive accuracy than those of classic models. Conclusions: COSSH-ACLFs, with a superior predictive accuracy compared with other classical scores, can strongly predict short-term prognosis in Chinese patients with HBV-ACLF.
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Maipang K, Potranun P, Chainuvati S, Nimanong S, Chotiyaputta W, Tanwandee T, Charatcharoenwitthaya P. Validation of the prognostic models in acute-on-chronic liver failure precipitated by hepatic and extrahepatic insults. PLoS One 2019; 14:e0219516. [PMID: 31291342 PMCID: PMC6619802 DOI: 10.1371/journal.pone.0219516] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2019] [Accepted: 06/25/2019] [Indexed: 02/07/2023] Open
Abstract
Background Patients with acute-on-chronic liver failure (ACLF) precipitated by hepatic injury and extrahepatic insults had distinct clinical phenotypes, and prognosis. This study aimed to validate prognostic models for ACLF and to explore their discriminative abilities in ACLF population categorized by the etiologies of precipitating events. Methods This study collected data from 343 consecutive cirrhotic patients hospitalized with the diagnosis of ACLF according to the EASL-CLIF-Consortium definition. The discrimination abilities of prognostic models at the onset of ACLF were tested with the concordance index and area under the receiver operating characteristic curve. Results Among the entire cohort, 103 patients survived with medical management, nine patients were transplanted, and 231 patients died without liver transplantation. The predictive accuracy of the Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) for 28-day mortality was similar to the CLIF Consortium Organ Failure (CLIF-C OF) but significantly higher than the CLIF Consortium ACLF, the Child-Turcotte-Pugh, the model for end-stage liver disease (MELD), the MELD-sodium, the integrated MELD, and the Acute Physiology and Chronic Health Evaluation II. Of note, 44 patients had acute hepatic insult triggering ACLF (hepatic-ACLF), 244 were exclusively precipitated by bacterial infection or gastrointestinal bleeding (extrahepatic-ACLF), and 55 cases had no any identifiable potential precipitating events. Patients with hepatic-ACLF had significantly higher 28-day mortality than extrahepatic-ACLF patients. The CLIF-SOFA and CLIF-C OF displayed the highest accuracy significantly outperforming other scoring systems in predicting mortality among patients with hepatic-ACLF and those with extrahepatic-ACLF. Conclusion The CLIF-SOFA and simpler CLIF-C OF are reliable measures of mortality risk in ACLF patients precipitated by either hepatic or extrahepatic insults. Both validated models could be used to stratify the risk of death and improve management of ACLF.
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Affiliation(s)
- Kotchakon Maipang
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Pichanun Potranun
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Siwaporn Chainuvati
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Supot Nimanong
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Watcharasak Chotiyaputta
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Tawesak Tanwandee
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Phunchai Charatcharoenwitthaya
- Department of Medicine, Division of Gastroenterology, Faculty of Medicine, Siriraj Hospital, Mahidol University, Bangkok, Thailand
- * E-mail:
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Bansho ETO, Silva PES, Colombo BS, Wildner LM, Bazzo ML, Dantas-Corrêa EB, Schiavon LL, Narciso-Schiavon JL. Prognostic Significance of The New Criteria for Acute Kidney Injury in Cirrhosis. Ann Hepatol 2019; 17:461-469. [PMID: 29735786 DOI: 10.5604/01.3001.0011.7390] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND New criteria for acute kidney injury (AKI) in cirrhosis have been proposed, but its prognostic significance is unclear. This study aims to evaluate the prognostic significance of the AKI criteria in cirrhotic patients hospitalized for acute decompensation. MATERIAL AND METHODS This is a prospective cohort study. AKI was defined as an increase in creatinine (Cr) levels ≥ 0.3 mg/dL in 48 h or ≥ 50% of the basal value in the last 7d. AKI was divided into stages 1 (elevation: < 2x basal), 2 (2 or 3x), and 3 (> 3x). RESULTS In this study, 227 patients aged 53.9 ± 11.5 years were included, of whom 37% had AKI (28% AKI1, 5% AKI2, and 4% AKI3). Thirty percent of the patients died or were transplanted within 90 days from causes related to the presence of ascites at hospital admission and higher values of Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) scores, but not to the presence of AKI. In a regression analysis conducted to assess the effect of the final Cr level in patients with AKI, 90-day mortality was associated with ascites, higher CLIF-SOFA score, and AKI with final Cr level ≥ 1.5 mg/dL. The patients with AKI with Cr levels ≥ 1.5 mg/dL showed lower transplant-free survival rates than those without AKI, and those with AKI1 with final Cr level < 1.5 mg/dL. CONCLUSIONS Early AKI was frequent and associated with 90-day mortality or transplantation only when the final Cr level was ≥ 1.5 mg/dL. Distinct approaches are needed for patients with AKI1 according to final Cr.
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Affiliation(s)
- Emilia T O Bansho
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Pedro Eduardo S Silva
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Bruno S Colombo
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Letícia M Wildner
- Department of Clinical Analysis, University Hospital Polydoro Ernani de São Thiago-Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Maria Luiza Bazzo
- Department of Clinical Analysis, University Hospital Polydoro Ernani de São Thiago-Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Esther B Dantas-Corrêa
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Leonardo L Schiavon
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis, SC, Brazil
| | - Janaína L Narciso-Schiavon
- Núcleo de Estudos em Gastroenterologia e Hepatologia, Internal Medicine Department, Federal University of Santa Catarina, Florianopolis, SC, Brazil
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Wu SL, Zheng YX, Tian ZW, Chen MS, Tan HZ. Scoring systems for prediction of mortality in decompensated liver cirrhosis: A meta-analysis of test accuracy. World J Clin Cases 2018; 6:995-1006. [PMID: 30568954 PMCID: PMC6288518 DOI: 10.12998/wjcc.v6.i15.995] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/14/2018] [Revised: 11/08/2018] [Accepted: 11/14/2018] [Indexed: 02/05/2023] Open
Abstract
AIM To compare the accuracy of the scoring systems Child-Turcotte-Pugh (CTP), Model for End-stage Liver Disease score (MELD), MELD-Na, and MELD to Serum Sodium ratio (MESO) to predict the mortality in decompensated liver cirrhosis. METHODS The PubMed, Web of Science, Cochrane Library, EMBASE, and Ovid databases were systematically searched from inception to September 2018 for relevant articles, and we evaluated the quality of the included studies. The accuracy of scoring systems was analyzed with Stata 12 and MetaDiSc 1.4. RESULTS Sixteen studies involving 2337 patients were included. The pooled areas under the summary receiver operating characteristic curves (AUROCs) of CTP, MELD, MELD-Na, and MESO to predict mortality were 0.81, 0.78, 0.85, and 0.86, respectively. Within 3 mo, the AUROCs of CTP, MELD, and MELD-Na in predicting mortality were 0.78, 0.76, and 0.89, respectively. The AUROCs of CTP, MELD, and MELD-Na at 3 mo were 0.86, 0.78, and 0.86, respectively. The AUROCs of CTP, MELD, and MELD-Na at 6 mo were 0.91, 0.83, and 0.90, respectively. The AUROCs of CTP, MELD, and MELD-Na at 12 mo were 0.72, 0.75 and 0.84, respectively. In cirrhotic patients with bleeding, the AUROCs of CTP and MELD were 0.76 and 0.88, respectively. CONCLUSION MESO has the highest AUROC in all assessed scoring systems. Considering the different time points, MELD-Na has good accuracy in predicting the mortality of decompensated liver cirrhosis. Compared to CTP, MELD is better in predicting variceal bleeding.
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Affiliation(s)
- Shi-Lan Wu
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan Province, China
| | - Yi-Xiang Zheng
- Department of Infectious Diseases, Xiangya Hospital, Central South University, Changsha 410000, Hunan Province, China
| | - Zheng-Wen Tian
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan Province, China
| | - Meng-Shi Chen
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan Province, China
| | - Hong-Zhuan Tan
- Department of Epidemiology and Health Statistics, Xiangya School of Public Health, Central South University, Changsha 410000, Hunan Province, China
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Safi W, Elnegouly M, Schellnegger R, Umgelter K, Geisler F, Reindl W, Saugel B, Hapfelmeier A, Umgelter A. Infection and Predictors of Outcome of Cirrhotic Patients after Emergency Care Hospital Admission. Ann Hepatol 2018; 17:948-958. [PMID: 30600289 DOI: 10.5604/01.3001.0012.7195] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
INTRODUCTION AND AIMS We aimed to explore the impact of infection diagnosed upon admission and of other clinical baseline parameters on mortality of cirrhotic patients with emergency admissions. MATERIAL AND METHODS We performed a prospective observational monocentric study in a tertiary care center. The association of clinical parameters and established scoring systems with short-term mortality up to 90 days was assessed by univariate and multivariable Cox regression analysis. Akaike's Information Criterion (AIC) was used for automated variable selection. Statistical interaction effects with infection were also taken into account. RESULTS 218 patients were included. 71.2% were male, mean age was 61.1 ± 10.5 years. Mean MELD score was 16.2 ± 6.5, CLIF-consortium Acute on Chronic Liver Failure-score was 34 ± 11. At 28, 90 and 365 days, 9.6%, 26.0% and 40.6% of patients had died, respectively. In multivariable analysis, respiratory organ failure [Hazard Ratio (HR) = 0.15], albumin substitution (HR = 2.48), non-HCC-malignancy (HR = 4.93), CLIF-C-ACLF (HR = 1.10), HCC (HR = 3.70) and first episode of ascites (HR = 0.11) were significantly associated with 90-day mortality. Patients with infection had a significantly higher 90-day mortality (36.3 vs. 20.1%, p = 0.007). Cultures were positive in 32 patients with resistance to cephalosporins or quinolones in 10, to ampicillin/sulbactam in 14 and carbapenems in 6 patients. CONCLUSION Infection is common in cirrhotic ED admissions and increases mortality. The proportion of resistant microorganisms is high. The predictive capacity of established scoring systems in this setting was low to moderate.
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Affiliation(s)
- Wajima Safi
- 4th Medical Department, Klinikum Süd, Friedrich-Alexander-University Erlangen-Nuremberg, Germany
| | - Mayada Elnegouly
- 2nd Medical Department, Technische Universität München, Klinikum rechts der Isar, Germany
| | | | - Katrin Umgelter
- Department of Anaesthesiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany, Klinik für operative Intensivmedizin, Vivantes Humboldt Klinikum, Berlin, Germany
| | - Fabian Geisler
- 2nd Medical Department, Technische Universität München, Klinikum rechts der Isar, Germany
| | - Wolfgang Reindl
- 2nd Medical Department, Universitätsmedizin Mannheim, Germany
| | - Bernd Saugel
- Department of Anesthesiology, Center of Anesthesiology and Intensive Care Medicine, University Medical Center, Hamburg-Eppendorf, Germany
| | - Alexander Hapfelmeier
- Institute of Medical Statistics and Epidemiology, Technische Universität München, Germany
| | - Andreas Umgelter
- 2nd Medical Department, Technische Universität München, Klinikum rechts der Isar, Germany
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EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol 2018; 69:406-460. [PMID: 29653741 DOI: 10.1016/j.jhep.2018.03.024] [Citation(s) in RCA: 1515] [Impact Index Per Article: 252.5] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/28/2018] [Accepted: 03/28/2018] [Indexed: 02/06/2023]
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Narciso-Schiavon JL, Pereira JG, Silva TE, Bansho ETO, Morato EF, Pinheiro JT, Muraro-Wildner L, Bazzo ML, Dantas-Corrêa EB, Schiavon LL. Circulating levels of pentraxin-3 (PTX3) in patients with liver cirrhosis. Ann Hepatol 2018; 16:780-787. [PMID: 28809733 DOI: 10.5604/01.3001.0010.2789] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
BACKGROUND Despite the circulating levels of PTX3 were related to the severity of various diseases, there are no studies investigating its role in patients with liver cirrhosis. We aimed to study PTX3 levels in patients with liver cirrhosis. MATERIAL AND METHODS A prospective cohort study included 130 patients hospitalized for acute decompensation of liver cirrhosis, 29 stable cirrhotic outpatients and 32 healthy controls evaluated in a tertiary hospital in Southern Brasil. RESULTS The median PTX3 level was significantly higher in stable cirrhotic patients compared to controls (2.6 vs. 1.1 ng/mL; p < 0.001), hospitalized cirrhotic patients compared to controls (3.8 vs. 1.1 ng/mL; p < 0.001), and hospitalized cirrhotic patients compared to stable cirrhotic patients (3.8 vs. 2.6 ng/mL; p = 0.001). A positive correlation was found between PTX3 and serum creatinine (r = 0.220; p = 0.012), Chronic Liver Failure - Sequential Organ Failure Assessment score (CLIF-SOFA) (r = 0.220; p = 0.010), MELD (r = 0.279; p = 0.001) and Child-Pugh score (r = 0.224; p = 0.010). Significantly higher levels of PTX3 were observed in patients on admission with ACLF (8.9 vs. 3.1 ng/mL; p < 0.001) and MELD score ≥ 20 (6.6 vs. 3.4 ng/mL; p = 0.002). Death within 90 days occurred in 30.8% of patients and was associated with higher levels of PTX3 (5.3 vs. 3.4 ng/mL; p = 0.009). The probability of Kaplan-Meier survival was 77.0% in patients with PTX-3 < 5.3 ng mL (upper tercile) and 53.5% in those with PTX3 ≥ 5.3 ng/mL (p = 0.002). CONCLUSION These results indicate the potential for use of PTX3 as an inflammatory biomarker for the prognosis of patients with hepatic cirrhosis.
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Affiliation(s)
- Janaína L Narciso-Schiavon
- Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil Núcleo de Estudos em Gastroenterologia e Hepatologia, Department of Internal Medicine
| | - Jéssica G Pereira
- Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil Núcleo de Estudos em Gastroenterologia e Hepatologia, Department of Internal Medicine
| | - Telma Erotides Silva
- Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil Núcleo de Estudos em Gastroenterologia e Hepatologia, Department of Internal Medicine
| | - Emília T O Bansho
- Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil Núcleo de Estudos em Gastroenterologia e Hepatologia, Department of Internal Medicine
| | - Edelton F Morato
- University Hospital Polydoro Ernani de São Thiago - Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil Postgraduate Program in Medical Sciences
| | - José T Pinheiro
- University Hospital Polydoro Ernani de São Thiago - Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil Center for Assessment of Allergic Type Reactions to Drugs
| | - Letícia Muraro-Wildner
- University Hospital Polydoro Ernani de São Thiago - Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil Clinical Analysis Laboratory
| | - Maria Luiza Bazzo
- Department of Clinical Analysis. Federal University of Santa Catarina. Brasil
| | | | - Leonardo L Schiavon
- Federal University of Santa Catarina, Florianópolis, Santa Catarina, Brazil Núcleo de Estudos em Gastroenterologia e Hepatologia, Department of Internal Medicine
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Song DS, Kim TY, Kim DJ, Kim HY, Sinn DH, Yoon EL, Kim CW, Jung YK, Suk KT, Lee SS, Lee CH, Kim TH, Choe WH, Yim HJ, Kim SE, Baik SK, Jang JY, Kim HS, Kim SG, Yang JM, Sohn JH, Choi EH, Cho HC, Jeong SW, Kim MY. Validation of prognostic scores to predict short-term mortality in patients with acute-on-chronic liver failure. J Gastroenterol Hepatol 2018; 33:900-909. [PMID: 28921629 DOI: 10.1111/jgh.13991] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2017] [Revised: 08/16/2017] [Accepted: 09/02/2017] [Indexed: 12/11/2022]
Abstract
BACKGROUND AND AIM The aim of this study was to validate the chronic liver failure-sequential organ failure assessment score (CLIF-SOFAs), CLIF consortium organ failure score (CLIF-C OFs), CLIF-C acute-on-chronic liver failure score (CLIF-C ACLFs), and CLIF-C acute decompensation score in Korean chronic liver disease patients with acute deterioration. METHODS Acute-on-chronic liver failure was defined by either the Asian Pacific Association for the study of the Liver ACLF Research Consortium (AARC) or CLIF-C criteria. The diagnostic performances for short-term mortality were compared by the area under the receiver operating characteristic curve. RESULTS Among a total of 1470 patients, 252 patients were diagnosed with ACLF according to the CLIF-C (197 patients) or AARC definition (95 patients). As the ACLF grades increased, the survival rates became significantly lower. The areas under the receiver operating characteristic of the CLIF-SOFAs, CLIF-C OFs, and CLIF-C ACLFs were significantly higher than those of the Child-Pugh, model for end-stage liver disease, and model for end-stage liver disease-Na scores in ACLF patients according to the CLIF-C definition (all P < 0.05), but there were no significant differences in patients without ACLF or in patients with ACLF according to the AARC definition. The CLIF-SOFAs, CLIF-C OFs, and CLIF-C ACLFs had higher specificities with a fixed sensitivity than liver specific scores in ACLF patients according to the CLIF-C definition, but not in ACLF patients according to the AARC definition. CONCLUSIONS The CLIF-SOFAs, CLIF-C OFs, and CLIF-C ACLFs are useful scoring systems that provide accurate information on prognosis in patients with ACLF according to the CLIF-C definition, but not the AARC definition.
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Affiliation(s)
- Do Seon Song
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Tae Yeob Kim
- Institute of Medical Science, Hanyang University, Seoul, Korea
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Hee Yeon Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Dong Hyun Sinn
- Department of Internal Medicine, Samsung Medical Center, Seoul, Korea
| | - Eileen L Yoon
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Korea
| | - Chang Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Young Kul Jung
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea
| | - Sang Soo Lee
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Chang Hyeong Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Korea
| | - Tae Hun Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Won Hyeok Choe
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Hyoung Su Kim
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Korea
| | - Eun Hee Choi
- Institute of Lifestyle Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
| | - Hyun Chin Cho
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Korea
| | - Soung Won Jeong
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Korea
| | - Moon Young Kim
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Korea
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Wu J, Li YY, Hu JH, Jia L, Shi M, Meng FP, Li J, Zhao J, Wang FS, Meng QH. Differential characteristics and prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure defined by European Association for the Study of the Liver - Chronic Liver Failure criteria. Hepatol Res 2018; 48:153-164. [PMID: 28456135 DOI: 10.1111/hepr.12909] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2017] [Revised: 04/18/2017] [Accepted: 04/28/2017] [Indexed: 12/18/2022]
Abstract
AIM To determine the differential characteristics and prognosis of patients with hepatitis B virus (HBV)-related acute-on-chronic liver failure (ACLF) detected using Asian Pacific Association for the Study of the Liver (APASL) criteria and then classified using European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) criteria. METHODS We retrospectively reviewed 316 HBV-related APASL ACLF patients treated at Beijing 302 Hospital or Beijing You'An Hospital (both Beijing, China) between February 2015 and February 2016. Clinical characteristics and mortality rates were compared among patients with different EASL-CLIF ACLF severity grades (no ACLF, and ACLF grades 1-3). RESULTS According to the EASL-CLIF criteria, 138 patients had no ACLF, 123 had ACLF at enrollment, and 55 developed ACLF during hospitalization. Both 28-day and 90-day transplant-free mortality were dramatically lower in patients without EASL-CLIF ACLF (0.7% and 5.1%, respectively) than in patients with EASL-CLIF ACLF (40.7% and 63.2%, respectively; both P < 0.001). Liver failure rates were similar in patients with and without EASL-CLIF ACLF, but extrahepatic organ failure was rare in patients without EASL-CLIF ACLF. Baseline serum creatinine, new bacterial infection and new acute kidney injury during hospitalization, maximum rising rates of CLIF-C ACLF score, and Model for End-stage Liver Disease score were independent predictors of EASL-CLIF ACLF after enrollment. CONCLUSIONS The EASL-CLIF ACLF classification can accurately prognosticate the short-term mortality of patients with HBV-related APASL ACLF. It can also distinguish distinct clinical characteristics and prognoses in patients with and without EASL-CLIF ACLF.
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Affiliation(s)
- Juan Wu
- Department of Infectious Diseases, 302 Military Hospital of China - Peking University Teaching Hospital, Beijing, China
| | - Yuan-Yuan Li
- Department of Infectious Diseases, 302 Military Hospital of China - Peking University Teaching Hospital, Beijing, China
| | - Jin-Hua Hu
- Medical Center for Liver Failure, Beijing 302 Hospital, Beijing, China
| | - Lin Jia
- Department of Critical Care Medicine of Liver Disease, Beijing You'An Hospital, Capital Medical University, Beijing, China
| | - Ming Shi
- Department of Infectious Diseases, 302 Military Hospital of China - Peking University Teaching Hospital, Beijing, China
| | - Fan-Ping Meng
- Department of Infectious Diseases, 302 Military Hospital of China - Peking University Teaching Hospital, Beijing, China
| | - Juan Li
- Department of Critical Care Medicine of Liver Disease, Beijing You'An Hospital, Capital Medical University, Beijing, China
| | - Juan Zhao
- Department of Critical Care Medicine of Liver Disease, Beijing You'An Hospital, Capital Medical University, Beijing, China
| | - Fu-Sheng Wang
- Department of Infectious Diseases, 302 Military Hospital of China - Peking University Teaching Hospital, Beijing, China
| | - Qing-Hua Meng
- Department of Critical Care Medicine of Liver Disease, Beijing You'An Hospital, Capital Medical University, Beijing, China
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Alexopoulou A, Vasilieva L, Mani I, Agiasotelli D, Pantelidaki H, Dourakis SP. Single center validation of mortality scores in patients with acute decompensation of cirrhosis with and without acute-on-chronic liver failure. Scand J Gastroenterol 2017; 52:1385-1390. [PMID: 28851246 DOI: 10.1080/00365521.2017.1369560] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVES Acute decompensation (AD) of cirrhosis is characterized by high mortality. We aimed to validate the performance in predicting mortality of both the chronic-liver-failure-consortium (CLIF-C) acute-on-chronic liver failure (ACLF) and CLIF-C AD scores in a cohort of patients admitted for AD. METHODS In this prospective cohort study, patients were followed-up during their hospital stay and for 365 days thereafter. RESULTS About 182 patients with AD were enrolled including 78 (42.8%) who met the criteria for ACLF (ACLF-group) while the remaining had AD without ACLF (AD-group). 56.4% and 56.7% of the ACLF- and AD-groups, respectively, had alcoholic cirrhosis and 85.9% of the ACLF-group hepatic encephalopathy. Only few patients were hospitalized in the intensive care unit (ICU) or transplanted. The probabilities of death estimated for both scores were similar to the overall mortality rates observed at all time points. The model had a good fit in the AD-group at 90 days (p = .974) but a worse, yet adequate, in the ACLF-group at 28 days (p = .08). The CLIF-C ACLF or AD scores had an adequate, predictive discrimination ability for mortality at all time points, with Harrel's concordance index-C ranging between 0.64 and 0.65 or 0.64 and 0.68, respectively. Both scores showed a similar predictive accuracy for mortality compared to those of MELD, MELD-Na and Child-Pugh. CONCLUSIONS In this population without access to appropriate ICU treatment, the CLIF-C ACLF and AD performed worse than in studies with patients having ICU access. In addition, the CLIF scores were not superior to classical ones in this setting.
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Affiliation(s)
- Alexandra Alexopoulou
- a 2nd Department of Medicine , Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Larisa Vasilieva
- a 2nd Department of Medicine , Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Iliana Mani
- a 2nd Department of Medicine , Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Danai Agiasotelli
- a 2nd Department of Medicine , Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Helen Pantelidaki
- a 2nd Department of Medicine , Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
| | - Spyros P Dourakis
- a 2nd Department of Medicine , Medical School, National and Kapodistrian University of Athens, Hippokration General Hospital , Athens , Greece
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Sun DQ, Zheng CF, Liu WY, Van Poucke S, Mao Z, Shi KQ, Wang XD, Wang JD, Zheng MH. AKI-CLIF-SOFA: a novel prognostic score for critically ill cirrhotic patients with acute kidney injury. Aging (Albany NY) 2017; 9:286-296. [PMID: 28114104 PMCID: PMC5310668 DOI: 10.18632/aging.101161] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2016] [Accepted: 01/15/2017] [Indexed: 12/22/2022]
Abstract
Critically ill cirrhotic patients with acute kidney injury (AKI) are associated with high mortality rates. The aims of this study were to develop a specific prognostic score for critically ill cirrhotic patients with AKI, the acute kidney injury - Chronic Liver Failure - Sequential Organ Failure- Assessment score (AKI-CLIF-SOFA) score. This study focused on 527 cirrhotic patients with AKI admitted to intensive care unit and constructed a new scoring system, the AKI-CLIF-SOFA, which can be used to prognostically assess mortality in these patient population. Parameters included in this model were analysed by cox regression. The area under the receiver operating characteristic curve (auROC) of AKI-CLIF-SOFA scoring system was 0.74 in 30 days, 0.74 in 90 days, 0.72 in 270 days and 0.72 in 365 days. Additionally, this study demonstrated that the new model had more discriminatory power than chronic liver failure- sequential organ failure assessment score (CLIF-SOFA), SOFA, model for end stage liver disease (MELD), kidney disease improving global outcomes (KDIGO) and simplified acute physiology score II (SAPS II) (auROC: 0.72, 0.66, 0.64, 0.62, 0.63 and 0.65 respectively, all P < 0.05) for the prediction of the 365-days mortality. Therefore, AKI-CLIF-SOFA demonstrated a valuable discriminative ability compared with KDIGO, CLIF-SOFA, MELD, SAPS II and SOFA in critically ill cirrhotic patients with AKI.
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Affiliation(s)
- Dan-Qin Sun
- Department of Nephrology, Affiliated Wuxi Second Hospital, Nanjing Medical University, Wuxi 214002, China
| | - Chen-Fei Zheng
- Department of Nephrology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Wen-Yue Liu
- Department of Endocrinology, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China
| | - Sven Van Poucke
- Department of Anesthesiology, Intensive Care, Emergency Medicine and Pain Therapy, Ziekenhuis Oost-Limburg, Genk, Belgium
| | - Zhi Mao
- Department of Critical Care Medicine, Chinese People's Liberation Army General Hospital, Beijing, China
| | - Ke-Qing Shi
- Department of Hepatology, Liver Research Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China.,Institute of Hepatology, Wenzhou Medical University, Wenzhou 325000, China
| | - Xiao-Dong Wang
- Department of Hepatology, Liver Research Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China.,Institute of Hepatology, Wenzhou Medical University, Wenzhou 325000, China
| | - Ji-Dong Wang
- Department of Nephrology, Affiliated Wuxi Second Hospital, Nanjing Medical University, Wuxi 214002, China
| | - Ming-Hua Zheng
- Department of Hepatology, Liver Research Center, the First Affiliated Hospital of Wenzhou Medical University, Wenzhou 325000, China.,Institute of Hepatology, Wenzhou Medical University, Wenzhou 325000, China
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Picon RV, Bertol FS, Tovo CV, de Mattos AZ. Chronic liver failure-consortium acute-on-chronic liver failure and acute decompensation scores predict mortality in Brazilian cirrhotic patients. World J Gastroenterol 2017; 23:5237-5245. [PMID: 28811718 PMCID: PMC5537190 DOI: 10.3748/wjg.v23.i28.5237] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Revised: 05/31/2017] [Accepted: 07/12/2017] [Indexed: 02/06/2023] Open
Abstract
AIM To validate prognostic scores for acute decompensation of cirrhosis and acute-on-chronic liver failure in Brazilian patients.
METHODS This is a prospective cohort study designed to assess the prognostic performance of the chronic liver failure-consortium (CLIF-C) acute decompensation score (CLIF-C AD) and CLIF-C acute-on-chronic liver failure score (CLIF-C ACLF), regarding 28-d and 90-d mortality, as well as to compare them to other prognostic models, such as Model for End-Stage Liver Disease (MELD), MELD Sodium (MELD-Na), Child-Pugh (CP) score, and the CLIF-C Organ Failure score (CLIF-C OF). All participants were adults with acute decompensation of cirrhosis admitted to the Emergency Department of a tertiary hospital in southern Brazil. Prognostic performances were evaluated by means of the receiver operating characteristic (ROC) curves, area under the curves (AUC) and 95%CI.
RESULTS One hundred and thirteen cirrhotic patients were included. At admission, 18 patients had acute-on-chronic liver failure (ACLF) and 95 individuals had acute decompensation (AD) without ACLF, of which 24 eventually developed ACLF during the course of hospitalization (AD evolving to ACLF group). The AD group had significantly lower 28-d (9.0%) and 90-d (18.3%) mortality as compared to the AD evolving to ACLF group and to the ACLF group (both P < 0.001). On the other hand, 28-d and 90-d mortalities were not significantly different between AD evolving to ACLF group and ACLF group (P = 0.542 and P = 0.708, respectively). Among patients with ACLF, at 28 d from the diagnosis, CLIF-C ACLF was the only score able to predict mortality significantly better than the reference line, with an AUC (95%CI) of 0.71 (95%CI: 0.54-0.88, P = 0.021). Among patients with AD, all prognostic scores performed significantly better than the reference line regarding 28-d mortality, presenting with similar AUCs: CLIF-C AD score 0.75 (95%CI: 0.63-0.88), CP score 0.72 (95%CI: 0.59-0.85), MELD score 0.75 (95%CI: 0.61-0.90), MELD-Na score 0.76 (95%CI: 0.61-0.90), and CLIF-C OF score 0.74 (95%CI: 0.60-0.88). The same occurred concerning AUCs for 90-d mortality: CLIF-C AD score 0.70 (95%CI: 0.57-0.82), CP score 0.73 (95%CI: 0.62-0.84), MELD score 0.71 (95%CI: 0.59-0.83), MELD-Na score 0.73 (95%CI: 0.62-0.84), and CLIF-C OF score 0.65 (95%CI: 0.52-0.78).
CONCLUSION This study demonstrated that CLIF-C ACLF is the best available score for the prediction of 28-d mortality among patients with ACLF. CLIF-C AD score is also useful for the prediction of mortality among cirrhotic patients with AD not fulfilling diagnostic criteria for ACLF, but it was not superior to other well-established prognostic scores.
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Marciano S, Mauro E, Dirchwolf M, Debernardi ME, Giunta D, Pagotto V, Rojas L, Gadano A. A Dynamic Definition of Acute Kidney Injury Does not Improve Prognosis Assessment in Acutely Decompensated Patients with Cirrhosis. J Clin Exp Hepatol 2017; 7:135-143. [PMID: 28663678 PMCID: PMC5478969 DOI: 10.1016/j.jceh.2017.03.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/25/2016] [Accepted: 03/01/2017] [Indexed: 02/07/2023] Open
Abstract
BACKGROUND/OBJECTIVES to compare the prognostic accuracy for 28 and 90-day transplant-free mortality of a modified CLIF-SOFA score (including a dynamic definition of acute kidney injury) with that of the classic CLIF-SOFA score and KDIGO score for acute kidney injury in patients with acute decompensation of cirrhosis. METHODS A retrospective analysis of all admissions of acutely decompensated patients with cirrhosis was carried out from January 2012 to December 2014. Classic and modified CLIF-SOFA scores were analyzed, as well as acute kidney injury diagnosis using the KDIGO score regarding their accuracy for 28- and 90-day transplant free mortality prediction. RESULTS 108 admissions were analyzed. Acute kidney injury diagnosis was met in 37 (34%) patients. Acute-on-chronic liver failure was diagnosed in 59 (55%) patients using the classic CLIF-SOFA score; and in 64 (59%) patients using the modified CLIF-SOFA score. Both CLIF-SOFA scores were highly effective in predicting 28-day transplant-free mortality (AUCROC 0.93 and 0.92, p = 0.34) as well as 90-day transplant-free mortality (AUCROC 0.79 and 0.78, p = 0.78). Acute kidney injury diagnosis had significantly lower accuracy in mortality assessment (28 and 90-day transplant free mortality AUCROC 0.67 [p = 0.002] and 0.63 [p = 0.02]). CONCLUSIONS To our knowledge, this is the first evidence of the limited impact of modifying the fixed kidney injury definition currently used for acute-on-chronic liver failure.
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Affiliation(s)
- Sebastián Marciano
- Liver Unit, Hospital Italiano, Buenos Aires, PC 1181, Argentina,Department of Research, Hospital Italiano, Buenos Aires, PC 1181, Argentina,Address for correspondence: Sección Hepatología, Hospital Italiano de Buenos Aires, Juan Domingo Perón 4190 - PC: 1181ACH - Ciudad Autónoma de Buenos Aires, Argentina.
| | - Ezequiel Mauro
- Liver Unit, Hospital Italiano, Buenos Aires, PC 1181, Argentina
| | | | - María Emilia Debernardi
- Internal Medicine, Centro de Educación Médica e Investigaciones Clínicas Norberto Quirno “CEMIC”, Buenos Aires, PC 1431, Argentina
| | - Diego Giunta
- Department of Research, Hospital Italiano, Buenos Aires, PC 1181, Argentina
| | - Vanina Pagotto
- Department of Research, Hospital Italiano, Buenos Aires, PC 1181, Argentina
| | - Liliana Rojas
- Department of Research, Hospital Italiano, Buenos Aires, PC 1181, Argentina
| | - Adrián Gadano
- Liver Unit, Hospital Italiano, Buenos Aires, PC 1181, Argentina,Department of Research, Hospital Italiano, Buenos Aires, PC 1181, Argentina
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Yin S, Wang SJ, Gu WY, Zhang Y, Chen LY, Li H. Risk of different precipitating events for progressing to acute-on-chronic liver failure in HBV-related cirrhotic patients. J Dig Dis 2017; 18:292-301. [PMID: 28485081 DOI: 10.1111/1751-2980.12480] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2017] [Revised: 04/24/2017] [Accepted: 05/05/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Acute-on-chronic liver failure (ACLF) is a distinct syndrome that develops in patients with cirrhosis and acute decompensation (AD). This study focused on the precipitating events (PEs) of hepatitis B virus (HBV)-related cirrhotic patients diagnosed as ACLF based on the Chronic Liver Failure Consortium organ failure (CLIF-C OF) score. METHODS Hospitalized patients with HBV-related cirrhosis and AD were retrospectively included. The patients' characteristics, laboratory test results, PEs, CLIF-C OF score and short-term prognosis were evaluated. RESULTS Of the 890 patients enrolled 300 (33.7%) were diagnosed as ACLF and 590 (66.3%) without ACLF. ACLF patients had a higher incidence of PEs than those without ACLF. The ACLF patients were more prone to having PEs of bacterial infection (P < 0.001), HBV reactivation (P < 0.001), active alcoholism (P = 0.036) and superimposed hepatitis virus infection (P = 0.031), whereas portal vein thrombosis (P = 0.002) were less common in the non-ACLF group. ACLF patients with the top four single PEs had diverse types of organ failures. However, they shared a similar short-term prognosis. While in patients without PEs the ACLF group had higher systemic inflammation and deterirated outcomes compared with the non-ACLF group. CONCLUSIONS PEs of bacterial infection, HBV reactivation, active alcoholism and superimposed hepatitis virus infection, but not GI hemorrhage or portal vein thrombosis, were risk factors for ACLF. There may be two types of patients with ACLF based on the differences in the clinical manifestation of the disease.
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Affiliation(s)
- Shan Yin
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Shi Jin Wang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Wen Yi Gu
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Yan Zhang
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Liu Ying Chen
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
| | - Hai Li
- Division of Gastroenterology and Hepatology, Key Laboratory of Gastroenterology and Hepatology, Ministry of Health, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai Institute of Digestive Disease, Shanghai, China
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Allegretti AS, Ortiz G, Kalim S, Wibecan J, Zhang D, Shan HY, Xu D, Chung RT, Karumanchi SA, Thadhani RI. Siglec-7 as a Novel Biomarker to Predict Mortality in Decompensated Cirrhosis and Acute Kidney Injury. Dig Dis Sci 2016; 61:3609-3620. [PMID: 27655105 PMCID: PMC5106324 DOI: 10.1007/s10620-016-4316-x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2016] [Accepted: 09/13/2016] [Indexed: 12/22/2022]
Abstract
BACKGROUND Patients with decompensated cirrhosis have high morbidity and are commonly hospitalized with acute kidney injury. AIMS We examined serum levels of Siglec-7, a transmembrane receptor that regulates immune activity, as a biomarker for mortality in patients with cirrhosis and acute kidney injury. METHODS Serum Siglec-7 was measured in hospitalized patients with cirrhosis and acute kidney injury, as well as in reference groups with acute liver injury/acute kidney injury, cirrhosis without acute kidney injury, and sepsis without liver disease. Clinical characteristics and subsequent outcomes were examined using univariate and multivariable analyses according to initial Siglec-7 levels. Primary outcome was death by 90 days. RESULTS One hundred twenty-eight subjects were included, 92 of which had cirrhosis and acute kidney injury and were used in the primary analysis. Average Model for End-Stage Liver Disease (MELD) score was 24 [95 % CI 23, 26], and serum creatinine was 2.5 [2.2, 2.8] mg/dL at the time Siglec-7 was measured. After adjusting for age and MELD score, high serum Siglec-7 level predicted mortality with a hazard ratio of 1.96 [1.04, 3.69; p = 0.04]. There was no difference in Siglec-7 levels by etiology of AKI (p = 0.24). Addition of serum Siglec-7 to MELD score improved discrimination for 90-day mortality [category-free net reclassification index = 0.38 (p = 0.04); integrated discrimination increment = 0.043 (p = 0.04)]. CONCLUSION Serum Siglec-7 was associated with increased mortality among hospitalized patients with cirrhosis and acute kidney injury. Addition of Siglec-7 to MELD score may increase discrimination to predict 90-day mortality.
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Affiliation(s)
- Andrew S. Allegretti
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Guillermo Ortiz
- Department of Medicine, St. Elizabeth’s Hospital, Boston, MA, USA
| | - Sahir Kalim
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Joshua Wibecan
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Dongsheng Zhang
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Hui Yi Shan
- Division of Nephrology and Hypertension, Department of Medicine, Keck School of Medicine of USC, Los Angeles, CA, USA
| | - Dihua Xu
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - Raymond T. Chung
- Liver Center and Gastrointestinal Division, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
| | - S. Ananth Karumanchi
- Division of Nephrology, Department of Medicine, Beth Israel Deaconess Medical Center, Boston, MA, USA
| | - Ravi I. Thadhani
- Division of Nephrology, Department of Medicine, Massachusetts General Hospital, Boston, MA, USA
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Colombo BDS, Ronsoni MF, Soares E Silva PE, Fayad L, Wildner LM, Bazzo ML, Dantas-Correa EB, Narciso-Schiavon JL, Schiavon LL. Prognostic significance of insulin-like growth factor-I serum levels in acute decompensation of cirrhosis. Biomarkers 2016; 22:127-132. [PMID: 27775431 DOI: 10.1080/1354750x.2016.1252949] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
CONTEXT IGF-I serum levels are suppressed in cirrhosis, but its prognostic significance is unknown. OBJECTIVES To investigate the prognostic value of IGF-I in patients admitted for acute decompensation of cirrhosis. MATERIALS AND METHODS Cohort study that included 103 patients. IGF-I was measured by enzyme-linked immunosorbent assay (ELISA). RESULTS Ninety-day mortality was 26.2% and it was independently associated with MELD, age and IGF-I. The Kaplan-Meier survival probability at 90 days was 94.3% in patients with IGF-I ≥13 ng/mL and 63.2% for patients with IGF-I <13 ng/mL (p = .001). DISCUSSION AND CONCLUSION IGF-I levels are independently associated with mortality in acute decompensation of cirrhosis.
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Affiliation(s)
| | | | | | - Leonardo Fayad
- a Division of Gastroenterology , Federal University of Santa Catarina , Florianópolis , Brazil
| | - Letícia Muraro Wildner
- b Department of Clinical Analysis , Federal University of Santa Catarina , Florianópolis , Brazil
| | - Maria Luiza Bazzo
- b Department of Clinical Analysis , Federal University of Santa Catarina , Florianópolis , Brazil
| | | | | | - Leonardo Lucca Schiavon
- a Division of Gastroenterology , Federal University of Santa Catarina , Florianópolis , Brazil
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Anand AC, Dhiman RK. Acute on Chronic Liver Failure-What is in a 'Definition'? J Clin Exp Hepatol 2016; 6:233-240. [PMID: 27746620 PMCID: PMC5052400 DOI: 10.1016/j.jceh.2016.08.011] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/22/2016] [Accepted: 08/26/2016] [Indexed: 12/12/2022] Open
Abstract
Acute on chronic liver failure (ACLF) is a recently recognized syndrome and its definition has been evolving over last two decades. Currently, there is no universal consensus about the definition as kind of cases being seen in the Western world appear to be somewhat different from those that are seen in Asia Pacific region. But every one agrees that definition of ACLF should include following components. (a) The status of pre-existing liver disease, (b) defining the acute insult that leads to rapid deterioration of liver status, (c) time frame during which the acute insult can lead to rapid deterioration, (d) the quantification and definition of liver failure status after deterioration, which will determine the severity of ACLF, and (e) prediction of prognosis after analyzing first four components in the short and long terms. There is some consensus that number of organ failures may be the main determinant of prognosis. Whatever the definition is being used, the central role that superadded infections play in ACLF cannot be denied and need to be tackled aggressively. Apart from that, recovery may be possible if the acute insult or the baseline disease is curable, i.e. with the use of nucleoside analogs for hepatitis B, and corticosteroids for severe autoimmune hepatitis. Development of dynamic criteria with observations in Hospital may improve our understanding of prognosis as well as our approach to the management of ACLF.
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Affiliation(s)
- Anil C. Anand
- Department of Hepatology and Gastroenterology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi 110076, India,Address for correspondence: Anil C. Anand, Senior Consultant Department of Hepatology and Gastroenterology, Indraprastha Apollo Hospital, Sarita Vihar, New Delhi 110076, India.Senior Consultant Department of Hepatology and Gastroenterology, Indraprastha Apollo HospitalSarita ViharNew Delhi110076India
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Sy E, Ronco JJ, Searle R, Karvellas CJ. Prognostication of critically ill patients with acute-on-chronic liver failure using the Chronic Liver Failure-Sequential Organ Failure Assessment: A Canadian retrospective study. J Crit Care 2016; 36:234-239. [PMID: 27569253 DOI: 10.1016/j.jcrc.2016.08.003] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 07/31/2016] [Accepted: 08/04/2016] [Indexed: 02/07/2023]
Abstract
PURPOSE We evaluated the Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) score to predict survival in a Canadian critically ill cohort with acute-on-chronic liver failure. METHODS We retrospectively examined 274 acute-on-chronic liver failure patients admitted to a quaternary level intensive care unit (ICU) between April 1, 2000, and April 30, 2011. We evaluated severity of illness scores, including the Acute Physiology and Chronic Health Evaluation (APACHE) II, model for end-stage liver disease (MELD), Child-Turcotte-Pugh (CTP), SOFA, and CLIF-SOFA. RESULTS On ICU admission, patients had the following median (interquartile range): APACHE II, 23 (19-28); MELD, 26 (19-35); CTP, 12 (10-13); SOFA, 15 (11-18); and CLIF-SOFA, 17 (13-21). In-hospital survival was 40%. There were no significant differences in survival for cirrhosis etiology, reason, or year of admission. The CLIF-SOFA score had the greatest area under receiver operating curve of 0.865 (95% confidence interval, 0.820-0.909) and outperformed the CTP, MELD, SOFA, and APACHE II scores. Sequential Organ Failure Assessment score performance improved on the third day of ICU admission (area under receiver operating curve, 0.935; 95% confidence interval, 0.895-0.975). CONCLUSIONS The CLIF-SOFA and SOFA scores during the first 3 days of ICU admission appear to be highly predictive of in-hospital mortality.
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Affiliation(s)
- Eric Sy
- Department of Critical Care, Regina General Hospital, Regina, Saskatchewan, Canada; Department of Medicine, University of Saskatchewan, Saskatoon, Saskatchewan, Canada; Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada.
| | - Juan J Ronco
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Rowan Searle
- Division of Critical Care Medicine, Department of Medicine, Faculty of Medicine, University of British Columbia, Vancouver, British Columbia, Canada
| | - Constantine J Karvellas
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Division of Gastroenterology, Department of Medicine, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada; Division of Transplantation, Department of Surgery, University of Alberta, Edmonton, Alberta, Canada; Liver Transplant Program, Alberta Health Services, Edmonton, Alberta, Canada
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