Complications constitute a major risk factor for mortality in hepatitis B virus-related acute-on-chronic liver failure patients: a multi-national study from the Asia–Pacific region
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Background and Aim
Cirrhosis is a controversial determinant of mortality in HBV-related acute-on-chronic liver failure (HBV–ACLF). The present study aimed to explore the effects of cirrhosis and the associated risk factors, especially its complications, on the outcome of HBV–ACLF.
A prospective–retrospective cohort of 985 patients was identified from the APASL–ACLF Research Consortium (AARC) database and the Chinese Study Group. Complications of ACLF (ascites, infection, hepatorenal syndrome, hepatic encephalopathy, upper gastrointestinal bleeding) as well as cirrhosis and the current main prognostic models were measured for their predictive ability for 28- or 90-day mortality.
A total of 709 patients with HBV–ACLF as defined by the AARC criteria were enrolled. Among these HBV–ACLF patients, the cirrhotic group showed significantly higher mortality and complications than the non-cirrhotic group. A total of 36.1% and 40.1% of patients met the European Association for the Study of Liver (EASL)–Chronic Liver Failure consortium (CLIF-C) criteria in the non-cirrhotic and cirrhotic groups, respectively; these patients had significantly higher rates of mortality and complications than those who did not satisfy the CLIF-C criteria. Furthermore, among patients who did not meet the CLIF-C criteria, the cirrhotic group exhibited higher mortality and complication rates than the non-cirrhotic group, without significant differences in organ failure. The Tongji prognostic predictor model score (TPPMs), which set the number of complications as one of the determinants, showed comparable or superior ability to the Chinese Group on the Study of Severe Hepatitis B–ACLF score (COSSH–ACLFs), APASL–ACLF Research Consortium score (AARC–ACLFs), CLIF-C organ failure score (CLIF–C OFs), CLIF-C–ACLF score (CLIF-C–ACLFs), Model for End-Stage Liver Disease score (MELDs) and MELD–sodium score (MELD–Nas) in HBV–ACLF patients, especially in cirrhotic HBV-–ACLF patients. Patients with two (OR 4.70, 1.88) or three (OR 8.27, 2.65) complications had a significantly higher risk of 28- or 90-day mortality, respectively.
The presence of complications is a major risk factor for mortality in HBV–ACLF patients. TPPM possesses high predictive ability in HBV–ACLF patients, especially in cirrhotic HBV–ACLF patients.
KeywordsHBV Acute-on-chronic liver failure Cirrhosis Prognostic scores Mortality
Acute-on-chronic liver failure
HBV-related acute-on-chronic liver failure
Asia-pacific association for the study of liver ACLF research consortium
ACLF research consortium score (AARC–ACLFs)
- CLIF-C OF
Chronic liver failure consortium organ failure
- CLIF-C ACLF
CLIF-C acute-on-chronic liver failure
Model for end-stage liver disease
Tongji prognostic predictor model
Chinese Group on the Study of Severe Hepatitis B-ACLF
Area under the receiver operating characteristic curve
The authors would like to thank Professor Osamu Yokosuka, Prof. Sombat Treeprasertsuk and Prof. Gamal Shiha for their support in valuable discussion and editing.
This study was partially supported by the National Thirteenth “Five Years” Project in Science and Technology of China (2017ZX10202201, 2018ZX10302-206).
Compliance with ethical standards
Conflict of interest
The authors declare no conflicts of interest about this work.
Informed consent in studies with human subjects
The data were collected using a pre-defined, web-based proforma in the Asia–pacific Association for the Study of Liver ACLF Research Consortium (AARC) database (http://www.aclf.in). Approval from the institutional ethics committees was obtained. The data were annotated and encrypted before analysis. All procedures followed were in accordance with the ethical standards of the responsible committee on human experimentation (Asia–pacific Association for the Study of Liver ACLF Research Consortium) and with the Helsinki Declaration of 1975, as revised in 2008 (5). Informed consent was obtained from all patients for being included in the study.
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