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Liver failure determines the outcome in patients of acute-on-chronic liver failure (ACLF): comparison of APASL ACLF research consortium (AARC) and CLIF-SOFA models

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Abstract

Background and aims

Acute-on-chronic liver failure (ACLF) is a progressive disease associated with rapid clinical worsening and high mortality. Early prediction of mortality and intervention can improve patient outcomes. We aimed to develop a dynamic prognostic model and compare it with the existing models.

Methods

A total of 1402 ACLF patients, enrolled in the APASL-ACLF Research Consortium (AARC) with 90-day follow-up, were analyzed. An ACLF score was developed in a derivation cohort (n = 480) and was validated (n = 922).

Results

The overall survival of ACLF patients at 28 days was 51.7%, with a median of 26.3 days. Five baseline variables, total bilirubin, creatinine, serum lactate, INR and hepatic encephalopathy, were found to be independent predictors of mortality, with AUROC in derivation and validation cohorts being 0.80 and 0.78, respectively. AARC-ACLF score (range 5–15) was found to be superior to MELD and CLIF SOFA scores in predicting mortality with an AUROC of 0.80. The point scores were categorized into grades of liver failure (Gr I: 5–7; II: 8–10; and III: 11–15 points) with 28-day cumulative mortalities of 12.7, 44.5 and 85.9%, respectively. The mortality risk could be dynamically calculated as, with each unit increase in AARC-ACLF score above 10, the risk increased by 20%. A score of ≥11 at baseline or persisting in the first week was often seen among nonsurvivors (p = 0.001).

Conclusions

The AARC-ACLF score is easy to use, dynamic and reliable, and superior to the existing prediction models. It can reliably predict the need for interventions, such as liver transplant, within the first week.

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Abbreviations

AARC:

APASL ACLF research consortium

ACLF:

Acute-on-chronic liver failure

HAV:

Hepatitis A virus

HCC:

Hepato-cellular carcinoma

HEV:

Hepatitis E virus

HBV:

Hepatitis B virus

SAH:

Severe alcoholic hepatitis

TJLB:

Trans-jugular liver biopsy

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Author information

Authors and Affiliations

  1. Department of Hepatology and Transplant, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India

    A. Choudhury, A. Jindal, R. Maiwall, M. K. Sharma, B. C. Sharma, V. Pamecha, P. Jain, P. Bhatia, G. Kumar & S. K. Sarin

  2. Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

    M. Mahtab & S. Rahman

  3. Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

    Y. K. Chawla & S. Taneja

  4. Department of Gastroenterology and Hepatology, Selayang Hospital, Kepong, Malaysia

    S. S. Tan

  5. Department of Gastroenterology and Hepatology, St John Medical College, Bangalore, India

    H. Devarbhavi

  6. Beijing Youan Hospital, Capital Medical University, Beijing, China

    Z. Duan & Chen Yu

  7. Department of Infectious Disease, Tongji Medical College, Tongji Hospital, Huazhong University of Science and Technology, Wuhan, China

    Q. Ning

  8. Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China

    Ji Dong Jia

  9. Department of Gastroenterology and Hepatology, Bombay Hospital and Medical Research Centre, Mumbai, India

    D. Amarapurkar

  10. Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India

    C. E. Eapen & A. Goel

  11. Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan

    S. S. Hamid, A. S. Butt & W. Jafri

  12. Hallym University Chuncheon Sacred Heart Hospital, Center for Liver and Digestive Diseases, Chuncheon, Gangwon-Do, Republic of Korea

    D. J. Kim

  13. Department of Hepatology, Nork Clinical Hospital of Infectious Diseases, Yerevan, Armenia

    H. Ghazinian

  14. Department of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore

    G. H. Lee

  15. Department of Gastroenterology, Dayanand Medical College, Ludhiana, India

    Ajit Sood

  16. Division of Hepatology, University of Indonesia, Jakarta, Indonesia

    L. A. Lesmana

  17. Department of Hepatogastroenterology, Sindh Institute of Urology and Transplantation, Karachi, Pakistan

    Z. Abbas

  18. Department of Internal Medicine, Egyptian Liver Research Institute and Hospital, Cairo, Egypt

    G. Shiha

  19. Department of Hepatology, Cardinal Santos Medical Center, Manila, Philippines

    D. A. Payawal

  20. Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey

    A. K. Dokmeci

  21. Cardinal Santos Medical Center, Metro Manila, Philippines

    J. D. Sollano & G. Carpio

  22. The Institute of Translational Hepatology, Beijing, China

    G. K. Lau

  23. Sir Salimur Rehman Medical College, Mitford Hospital, Dhaka, Bangladesh

    F. Karim

  24. Asian Institute of Gastroenterology, Hyderabad, India

    P. N. Rao

  25. Inserm, U1149, Centre de recherche sur l’Inflammation (CRI), UMR_S 1149, Labex INFLAMEX, Université Paris Diderot Paris 7, Paris, France

    R. Moreau

  26. Department of Hepatology, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India

    A. Choudhury, A. Jindal, R. Maiwall, M. K. Sharma, B. C. Sharma, P. Jain, G. Kumar & S. K. Sarin

  27. Department of Clinical Research, Institute of Liver and Biliary Sciences (ILBS), New Delhi, 110 070, India

    P. Bhatia

Authors
  1. A. Choudhury
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  2. A. Jindal
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  3. R. Maiwall
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  4. M. K. Sharma
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  5. B. C. Sharma
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  6. V. Pamecha
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  7. M. Mahtab
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  8. S. Rahman
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  9. Y. K. Chawla
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  10. S. Taneja
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  11. S. S. Tan
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  12. H. Devarbhavi
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  13. Z. Duan
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  14. Chen Yu
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  15. Q. Ning
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  16. Ji Dong Jia
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  17. D. Amarapurkar
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  18. C. E. Eapen
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  19. A. Goel
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  20. S. S. Hamid
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  21. A. S. Butt
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  22. W. Jafri
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  23. D. J. Kim
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  24. H. Ghazinian
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  25. G. H. Lee
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  26. Ajit Sood
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  27. L. A. Lesmana
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  28. Z. Abbas
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  29. G. Shiha
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  30. D. A. Payawal
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  31. A. K. Dokmeci
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  32. J. D. Sollano
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  33. G. Carpio
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  34. G. K. Lau
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  35. F. Karim
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  36. P. N. Rao
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  37. R. Moreau
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  38. P. Jain
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  39. P. Bhatia
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  40. G. Kumar
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  41. S. K. Sarin
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Consortia

APASL ACLF Working Party

Corresponding author

Correspondence to S. K. Sarin.

Ethics declarations

Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Approval of the institutional ethics committees was obtained.

Informed consent

Informed consent was taken from the patient or the next of kin.

Financial disclosures

None.

Electronic supplementary material

Appendix

Appendix

The study was approved by institute ethical committee vide letter no F/25/5/64/AC2013/912 and the respective centers also had their own ethical board approval for the study to be carried out. The centers, investigators and the number of patients contibuted are listed as follows:

Center no.

Name

Country/center

Total patients

1

Dr. Shiv K Sarin

ILBS, India

1286

5

Dr. Mamun-Al Mahtab

Bangladesh

145

6

Dr. Yogesh Chawala

Chandigarh

128

9

Dr. Tan SS

Malaysia

109

3

Dr. Harshad Devarbhavi

Bangalore

103

2

Dr. Zhongping Duan

Beijing

98

21

Dr. Qin Ning, Jidong Jia,

China

96

14

Dr. Deepak Naryan

Bombay Hospital

76

4

Dr. Eapen

Vellore

72

8

Dr. Saeed Hamid

Karachi, Pakistan

69

22

Dr. Kim et.al. 

Republic of Korea

68

13

Dr. Hasmik

Armenia

50

10

Dr. Guan Huei Lee

Singapore

39

7

Dr. Ajit sood

Ludhiana, India

34

12

Dr. Laurentius A. Lesmana

Indonesia

28

17

Dr. Zaigham Abbas

Pakistan

25

23

Dr. Gamal Shiha

Egypt

25

11

Dr. Diana Alcantara-Payawal

Philippines

21

20

Dr. A. Kadir Dokmeci

Turkey

19

16

Dr. Jose

Philippines

12

24

Dr. Man-Fung Yuen

Hong Kong

12

15

Dr. George K Lau

China

10

18

Dr. Fazal Karim

Bangladesh

6

19

Dr. P N Rao

Hyderabad, India

4

Total

  

2535

Complete data for analysis

1402

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Choudhury, A., Jindal, A., Maiwall, R. et al. Liver failure determines the outcome in patients of acute-on-chronic liver failure (ACLF): comparison of APASL ACLF research consortium (AARC) and CLIF-SOFA models. Hepatol Int 11, 461–471 (2017). https://doi.org/10.1007/s12072-017-9816-z

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  • DOI: https://doi.org/10.1007/s12072-017-9816-z

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