Acute-on-Chronic Liver Failure Is a Distinct Syndrome That Develops in Patients With Acute Decompensation of Cirrhosis
Acute-on-Chronic Liver Failure Is a Distinct Syndrome That Develops in Patients With Acute Decompensation of Cirrhosis
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DOI：
10.1053/j.gastro.2013.02.042
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发表时间：
2013-06-01
期刊：
影响因子：
29.4
通讯作者：
Arroyo, Vicente
中科院分区：
文献类型：
--
作者：
Moreau, Richard;Jalan, Rajiv;Arroyo, Vicente
背景与目的：因急性失代偿(AD)和器官衰竭而住院的肝硬变患者有即将死亡的危险，并被认为是急性-慢性肝衰竭(ACLF)。然而，目前尚无明确的ACLF诊断标准，因此对其发生发展情况知之甚少。我们的目标是确定ACLF的诊断标准，并描述这种综合征在欧洲AD患者中的发展情况。方法：我们收集了2011年2月至9月在8个欧洲国家的29个肝脏单位住院的1343名肝硬变和AD患者的数据。我们使用器官衰竭和死亡率数据来定义ACLF分级，评估死亡率，并确定ACLF和AD之间的差异。我们基于对器官衰竭患者(由慢性肝功能衰竭-器官衰竭序贯评估[CLIF-SOFA]评分定义)和高28天死亡率(15%)的分析，建立了ACLF的诊断标准。结果：在评估的患者中，303名患者在研究开始时有ACLF，112名患者发展为ACLF，928名患者没有ACLF。在研究开始时患有ACLF的患者中，28天的死亡率为33.9%，在发生ACLF的患者中为29.7%，在没有ACLF的患者中为1.9%。与无ACLF的患者相比，ACLF患者更年轻，更经常酗酒，有更多的合并细菌感染，有更多的白细胞数量和更高的血浆C-反应蛋白水平(P<；.001)。较高的CLIF-SOFA评分和白细胞计数是ACLF患者死亡率的独立预测因素。在没有AD病史的患者中，与有AD病史的患者相比，ACLF的器官衰竭数量、白细胞计数和死亡率都出人意料地高。结论：我们分析了来自肝硬变和AD患者的数据以建立急性肝功能衰竭的诊断标准，结果表明它不同于AD，不仅基于器官衰竭的存在(S)和高死亡率，而且还基于年龄、诱发事件和全身炎症。ACLF的死亡率与器官功能丧失和高白细胞计数有关。ACLF在无AD病史的患者中尤为严重。
BACKGROUND & AIMS: Patients with cirrhosis hospitalized for an acute decompensation (AD) and organ failure are at risk for imminent death and considered to have acute-on-chronic liver failure (ACLF). However, there are no established diagnostic criteria for ACLF, so little is known about its development and progression. We aimed to identify diagnostic criteria of ACLF and describe the development of this syndrome in European patients with AD. METHODS: We collected data from 1343 hospitalized patients with cirrhosis and AD from February to September 2011 at 29 liver units in 8 European countries. We used the organ failure and mortality data to define ACLF grades, assess mortality, and identify differences between ACLF and AD. We established diagnostic criteria for ACLF based on analyses of patients with organ failure (defined by the chronic liver failure-sequential organ failure assessment [ CLIF-SOFA] score) and high 28-day mortality rate (> 15%). RESULTS: Of the patients assessed, 303 had ACLF when the study began, 112 developed ACLF, and 928 did not have ACLF. The 28-day mortality rate among patients who had ACLF when the study began was 33.9%, among those who developed ACLF was 29.7%, and among those who did not have ACLF was 1.9%. Patients with ACLF were younger and more frequently alcoholic, had more associated bacterial infections, and had higher numbers of leukocytes and higher plasma levels of C-reactive protein than patients without ACLF (P < .001). Higher CLIF-SOFA scores and leukocyte counts were independent predictors of mortality in patients with ACLF. In patients without a prior history of AD, ACLF was unexpectedly characterized by higher numbers of organ failures, leukocyte count, and mortality compared with ACLF in patients with a prior history of AD. CONCLUSIONS: We analyzed data from patients with cirrhosis and AD to establish diagnostic criteria for ACLF and showed that it is distinct from AD, based not only on the presence of organ failure(s) and high mortality rate but also on age, precipitating events, and systemic inflammation. ACLF mortality is associated with loss of organ function and high leukocyte counts. ACLF is especially severe in patients with no prior history of AD.