背景:研究肝或肝外损伤引起的慢性急性肝衰竭(ACLF)的预后和死亡率预测因素的差异。
方法:前瞻性纳入肝硬化急性失代偿期患者,并从入院后随访90天。ACLF的定义基于慢性肝衰竭(CLIF)急性对慢性肝衰竭肝硬化(CANONIC研究)标准。由于急性病毒性肝炎A和E,急性恶化,乙型肝炎耀斑,酒精性肝炎,自身免疫性肝炎发作,或药物诱导的肝损伤被归类为肝ACLF和由于细菌感染,上消化道出血或手术作为肝外ACLF。同时有肝和肝外损伤的患者被纳入联合损伤组。
结果:在179例急性代偿失调患者中,122患有ACLF(肝损伤47和肝外损伤51)。酒精(64.8%)是肝硬化最常见的病因,而感染(36%)是最常见的急性损害,其次是酒精性肝炎(24.6%)。肝外ACLF患者有既往失代偿史的比例高于肝ACLF患者(62.7%vs.27.7%,P<0.001)。在28天和90天时,肝和肝外ACLF组的死亡率没有差异(53.2%vs.56.9%,P=0.715和85%vs.74.5%,分别为P=0.193)。肝外ACLF组28天死亡率的受试者-工作曲线下面积(AUROC)为0.788、0.724、0.718、0.634和0.726,而肝ACLF组为0.786、0.625、0.802、0.761和0.648,用于慢性肝功能衰竭-序贯器官衰竭评估(CLIF-SOFA),终末期肝病模型(MELD),综合MELD评分(IMELD),急性生理和慢性健康评估评分(APACHE-II),和Child-Turcotte-Pugh得分,分别。
结论:肝和肝外ACLF组在28和90天的死亡率没有差异。iMELD和CLIF-SOFA具有最高的AUROC来预测肝和肝外ACLF组的28天死亡率,分别。
BACKGROUND: To study the differences in outcome and predictors of mortality in acute-on-chronic liver failure (ACLF) precipitated by hepatic or extrahepatic insults.
METHODS: Consecutive patients of cirrhosis with acute decompensation were prospectively included and followed up for 90 days from admission. ACLF was defined based on chronic liver failure (CLIF) acute-on-chronic liver failure in cirrhosis (CANONIC study) criteria. Acute worsening due to acute viral hepatitis A and E, hepatitis B flare, alcoholic hepatitis, autoimmune hepatitis flare, or drug-induced liver injury were categorized as hepatic ACLF and that due to bacterial infection, upper gastrointestinal bleed or surgery as extrahepatic ACLF. Patients with both hepatic and extrahepatic insults were included in combined insult group.
RESULTS: Of 179 patients of acute decompensation, 122 had ACLF (hepatic insults 47 and extrahepatic insults 51). Alcohol (64.8%) was the most common etiology of cirrhosis while infection (36%) was the most common acute insult followed by alcoholic hepatitis (24.6%). Higher proportion of extrahepatic ACLF patients had history of prior decompensation than hepatic ACLF patients (62.7% vs. 27.7%, P < 0.001). There was no difference in mortality among hepatic and extrahepatic ACLF groups at 28 and 90 days (53.2% vs. 56.9%, P = 0.715 and 85% vs. 74.5%, P = 0.193, respectively). Area under receiver-operating curve (AUROC) for 28-day mortality in extrahepatic ACLF group was 0.788, 0.724, 0.718, 0.634, and 0.726 and in hepatic-ACLF group was 0.786, 0.625, 0.802, 0.761, and 0.648 for chronic liver failure-sequential organ failure assessment (CLIF-SOFA), model for end stage liver disease (MELD), integrated MELD score (iMELD), acute physiology and chronic health evaluation score (APACHE-II), and Child-Turcotte-Pugh score scores, respectively.
CONCLUSIONS: There is no difference in mortality among hepatic and extrahepatic ACLF groups at 28 and 90 days. iMELD and CLIF-SOFA have highest AUROC to predict 28-day mortality in hepatic and extrahepatic ACLF groups, respectively.