Meta-analysis of individual patient data of albumin dialysis in acute-on-chronic liver failure: focus on treatment intensity
Meta-analysis of individual patient data of albumin dialysis in acute-on-chronic liver failure: focus on treatment intensity
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DOI：
10.1177/1756284819879565
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发表时间：
2019-09-01
影响因子：
4.2
通讯作者：
Arroyo, Vicente
中科院分区：
文献类型：
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作者：
Banares, Rafael;Ibanez-Samaniege, Luis;Arroyo, Vicente
背景：慢性急性肝功能衰竭(ACLF)是一种常见的肝硬变并发症，以单器官或多器官衰竭为特征，短期死亡率高。治疗包括标准医疗(SMC)和器官(S)支持。人工肝支持(ALS)的疗效取决于ACLF的严重程度还是取决于这种治疗的强度，或者两者兼而有之，目前尚不清楚。本研究旨在进一步评估这些问题。方法：我们进行了个体患者数据荟萃分析，评估分子吸附再循环系统(MARS)在先前随机对照试验(RCT)中登记的ACLF患者的疗效。荟萃分析旨在评估患者严重程度(ACLF分级)和治疗强度[低强度治疗(LIT)、单用SMC或SMC加4次MARS疗程]对死亡率的影响。结果：在一项系统回顾中，确定了三个适用于Meta分析的随机对照试验(n=285，ACLF患者=165)。SMC加MARS(不管疗程数多少)与单独使用SMC相比并没有提高存活率，无论是在整个人群中还是在ACLF患者中。然而，在整个队列中，接受HIT和HIT的患者亚组的存活率显著提高(10天存活率：98.6%对82.8%，p=0.001；30天存活率：73.9%对64.3%，p=0.032)；在急性肝功能衰竭患者中(10天存活率：97.8%对78.6%，p=0.001；30天存活率：73.3%对58.5%，p=0.041)。值得注意的是，HIT提高了独立于ACLF分级的存活率。生存的独立预测因素是年龄、终末期肝病模型(MELD)、ACLF分级、接受MARS疗程的次数和MARS治疗的强度。结论：HIT联合白蛋白透析可提高ACLF患者的存活率。应在未来的临床试验中确定适当的治疗方案。
Background: Acute-on-chronic liver failure (ACLF) is a common complication of cirrhosis characterized by single or multiple organ failures and high short-term mortality. Treatment of ACLF consists of standard medical care (SMC) and organ(s) support. Whether the efficacy of artificial liver support (ALS) depends on the severity of ACLF or on the intensity of this treatment, or both, is unclear. This study aimed to further assess these issues. Methods: We performed an individual patient data meta-analysis assessing the efficacy of Molecular Adsorbent Recirculating System (MARS) in ACLF patients enrolled in prior randomized control trials (RCTs). The meta-analysis was designed to assess the effect of patient severity (ACLF grade) and treatment intensity [low-intensity therapy (LIT), SMC alone or SMC plus 4 MARS sessions] on mortality. Results: Three RCTs suitable for the meta-analysis (n = 285, ACLF patients = 165) were identified in a systematic review. SMC plus MARS (irrespective of the number of sessions) did not improve survival compared with SMC alone, neither in the complete population nor in the ACLF patients. Survival, however, was significantly improved in the subgroup of patients receiving HIT both in the entire cohort (10-day survival: 98.6% versus 82.8%, p = 0.001; 30-day survival: 73.9% versus 64.3%, p = 0.032) and within the ACLF patients (10-day survival: 97.8% versus 78.6%, p = 0.001; 30-day survival: 73.3% versus 58.5%, p = 0.041). Remarkably, HIT increased survival independently of ACLF grade. Independent predictors of survival were age, Model for End-Stage Liver Disease (MELD), ACLF grade, number of MARS sessions received, and intensity of MARS therapy. Conclusion: HIT with albumin dialysis may improve survival in patients with ACLF. Appropriate treatment schedules should be determined in future clinical trials.