Clinical Course of acute-on-chronic liver failure syndrome and effects on prognosis
Clinical Course of acute-on-chronic liver failure syndrome and effects on prognosis
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DOI：
10.1002/hep.27849
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发表时间：
2015-07-01
期刊：
影响因子：
13.5
通讯作者：
Arroyo, Vicente
中科院分区：
文献类型：
--
作者：
Gustot, Thierry;Fernandez, Javier;Arroyo, Vicente
急性慢性肝衰竭（ACLF）的特点是肝硬化急性失代偿（AD）、器官衰竭和28天高死亡率。我们调查了患者在特定时间点的评估是否预测了他们对肝移植（LT）的需求或他们的护理可能无效。我们评估了388名ACLF患者的临床病程，从2011年2月到9月，或在前瞻性多中心欧洲慢性肝衰竭（CLIF）肝硬化ACLF研究的早期（28天）随访期间。我们在不同时间点评估ACLF评分，以确定疾病消退、改善、恶化或稳定或波动的过程。ACLF缓解或改善的占49.2%，病程稳定或波动的占30.4%，恶化的占20.4%。非严重早期病程（最终无ACLF或ACLF-1）患者的28天无移植死亡率为低至中度（6%-18%），严重早期病程（最终ACLF-2或-3）患者的28天无移植死亡率为高至极高（42%-92%），与初始分级无关。病程严重程度的独立预测因子是CLIF Consortium ACLF评分（CLIF- c ACLF）和ACLF诊断时肝功能衰竭（总胆红素12mg /dL）的存在。81%的患者在1周时达到最终ACLF分级，从而准确预测3-7天内ACLF分级的短期（28天）和中期（90天）死亡率。在接受早期肝移植的患者中，75%的患者存活了至少1年。在4个器官衰竭的患者中，或在第3-7天发生的clifc - ACLFs为bb0 64，并且没有进行肝移植，28天死亡率为100%。结论：在综合征发生3-7天对ACLF患者进行评估，为确定LT的紧急程度提供了工具，并为因无效而终止重症监护提供了合理依据。(肝脏病学62:243 2015;252)
Acute-on-chronic liver failure (ACLF) is characterized by acute decompensation (AD) of cirrhosis, organ failure(s), and high 28-day mortality. We investigated whether assessments of patients at specific time points predicted their need for liver transplantation (LT) or the potential futility of their care. We assessed clinical courses of 388 patients who had ACLF at enrollment, from February through September 2011, or during early (28-day) follow-up of the prospective multicenter European Chronic Liver Failure (CLIF) ACLF in Cirrhosis study. We assessed ACLF grades at different time points to define disease resolution, improvement, worsening, or steady or fluctuating course. ACLF resolved or improved in 49.2%, had a steady or fluctuating course in 30.4%, and worsened in 20.4%. The 28-day transplant-free mortality was low-to-moderate (6%-18%) in patients with nonsevere early course (final no ACLF or ACLF-1) and high-to-very high (42%-92%) in those with severe early course (final ACLF-2 or -3) independently of initial grades. Independent predictors of course severity were CLIF Consortium ACLF score (CLIF-C ACLFs) and presence of liver failure (total bilirubin 12 mg/dL) at ACLF diagnosis. Eighty-one percent had their final ACLF grade at 1 week, resulting in accurate prediction of short- (28-day) and mid-term (90-day) mortality by ACLF grade at 3-7 days. Among patients that underwent early LT, 75% survived for at least 1 year. Among patients with 4 organ failures, or CLIF-C ACLFs >64 at days 3-7 days, and did not undergo LT, mortality was 100% by 28 days. Conclusions: Assessment of ACLF patients at 3-7 days of the syndrome provides a tool to define the emergency of LT and a rational basis for intensive care discontinuation owing to futility. (Hepatology 2015;62:243-252)