目的:关于慢性急性肝衰竭(ACLF)患者急性静脉曲张破裂出血(AVB)结局的数据有限,尤其是那些肝功能衰竭的患者。我们在APASLACLF研究联盟(AARC)的跨国队列中评估了ACLF患者的AVB结局。
方法:分析了AARC数据库中发生AVB(ACLF-AVB)的ACLF患者的前瞻性数据。这些数据包括人口统计,肝脏疾病的严重程度,6周内再出血和死亡率。将这些结果与与肝脏疾病严重程度相匹配的ACLF倾向评分匹配(PSM)队列进行比较(MELD,AARC评分)无AVB(ACLF无AVB)。
结果:在4434名ACLF患者中,ACLF-AVB的结局(n=72)[平均年龄-46±10.4岁,93%的男性,66%患有酒精性肝病,65%患有酒精性肝炎,AARC评分:10.1±2.2,MELD评分:34(IQR:27-40)]与以1:2(n=143)的比例选择的PSM队列进行比较[平均年龄-44.9±12.5岁,82.5%男性,48%酒精性肝病,55.7%酒精性肝炎,AARC评分:9.4±1.5,MELD评分:32(IQR:24-40)]ACLF-无AVB。尽管PSM,ACLF患者AVB的基线HVPG高于无AVB(25.00[IQR:23.00-28.00]vs.17.00[15.00-21.75]mmHg;p=0.045)。有或没有AVB的ACLF患者的6周死亡率分别为70.8%和53.8%。分别(p=0.025)。ACLF-AVB的6周再出血率为23%。存在腹水[危险比(HR)2.2(95%CI1.03-9.8),p=0.026],AVB[HR1.9(95%CI1.2-2.5,p=0.03)],和MELD评分[HR1.7(95%CI1.1-2.1),p=0.001]在整个ACLF队列中独立预测死亡率。
结论:AVB的发展导致6周死亡率高的ACLF患者预后不良。基线处HVPG升高代表ACLF中未来AVB的潜在风险因素。
OBJECTIVE: Limited data exist regarding outcomes of acute variceal bleeding (AVB) in patients with acute-on-chronic liver failure (ACLF), especially in those with hepatic failure. We evaluated the outcomes of AVB in patients with ACLF in a multinational cohort of APASL ACLF Research Consortium (AARC).
METHODS: Prospectively maintained data from AARC database on patients with ACLF who developed AVB (ACLF-AVB) was analysed. This data included demographic profile, severity of liver disease, and rebleeding and mortality in 6 weeks. These outcomes were compared with a propensity score matched (PSM) cohort of ACLF matched for severity of liver disease (MELD, AARC score) without AVB (ACLF without AVB).
RESULTS: Of the 4434 ACLF patients, the outcomes in ACLF-AVB (n = 72) [mean age-46 ± 10.4 years, 93% males, 66% with alcoholic liver disease, 65% with alcoholic hepatitis, AARC score: 10.1 ± 2.2, MELD score: 34 (IQR: 27-40)] were compared with a PSM cohort selected in a ratio of 1:2 (n = 143) [mean age-44.9 ± 12.5 years, 82.5% males, 48% alcoholic liver disease, 55.7% alcoholic hepatitis, AARC score: 9.4 ± 1.5, MELD score: 32 (IQR: 24-40)] of ACLF-without AVB. Despite PSM, ACLF patients with AVB had a higher baseline HVPG than without AVB (25.00 [IQR: 23.00-28.00] vs. 17.00 [15.00-21.75] mmHg; p = 0.045). The 6-week mortality in ACLF patients with or without AVB was 70.8% and 53.8%, respectively (p = 0.025). The 6-week rebleeding rate was 23% in ACLF-AVB. Presence of ascites [hazard ratio (HR) 2.2 (95% CI 1.03-9.8), p = 0.026], AVB [HR 1.9 (95% CI 1.2-2.5, p = 0.03)], and MELD score [HR 1.7 (95% CI 1.1-2.1), p = 0.001] independently predicted mortality in the overall ACLF cohort.
CONCLUSIONS: Development of AVB confers poor outcomes in patients with ACLF with a high 6-week mortality. Elevated HVPG at baseline represents a potential risk factor for future AVB in ACLF.