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AARC score determines outcomes in patients with alcohol-associated hepatitis: a multinational study

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Abstract

Background and aim

Acute-on-chronic liver failure (ACLF) is a severe form of alcoholic hepatitis (SAH). We aimed to study the natural course, response to corticosteroids (CS), and the role of the Asian Pacific Association for the Study of Liver (APASL) research consortium (AARC) score in determining clinical outcomes in AH patients.

Methods

Prospectively collected data from the AARC database were analyzed.

Results

Of the 1249 AH patients, (aged 43.8 ± 10.6 years, 96.9% male, AARC score 9.2 ± 1.9), 38.8% died on a 90 day follow-up. Of these, 150 (12.0%) had mild–moderate AH (MAH), 65 (5.2%) had SAH and 1034 (82.8%) had ACLF. Two hundred and eleven (16.9%) patients received CS, of which 101 (47.87%) were steroid responders by day 7 of Lille’s model, which was associated with improved survival [Hazard ratio (HR) 0.15, 95% CI 0.12–0.19]. AARC-ACLF grade 3 [OR 0.28, 0.14–0.55] was an independent predictor of steroid non-response and mortality [HR 3.29, 2.63–4.11]. Complications increased with degree of liver failure [AARC grade III vs. II vs I], bacterial infections [48.6% vs. 37% vs. 34.7%; p < 0.001); extrahepatic organ failure [66.9% vs. 41.8% vs. 35.4%; p < 0.001] respectively. The AARC score better discriminated 90-day mortality. Harrell’s C-index was 0.72 compared to other scores.

Conclusion

Nearly 4 of 5 patients with AH present with ACLF. Such patients have a higher risk of infections, organ failures, lower response to CS, and higher mortality. Patients with AH and ACLF with AARC grade 3 should be considered for an early liver transplant.

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Data availability

Data will be made available in excel format on request.

Abbreviations

AH:

Alcoholic hepatitis

SAH:

Severe alcoholic hepatitis

MDF:

Maddrey’s discriminant function

STOPAH:

Steroids or pentoxifylline for alcoholic hepatitis

CS:

Corticosteroids

MELD:

Model for end-stage liver disease score

GAHS:

Glasgow alcoholic hepatitis score

ACLF:

Acute-on-chronic liver failure

INR:

International normalized ratio

EASL-CLIF:

European study of liver (EASL.) Chronic liver failure

APASL:

Asian Pacific Association for the Study of the Liver

AARC:

Asian Pacific Association of Research Consortium

AST:

Aspartate aminotransferase

PaO2 :

Partial pressure of oxygen

FiO2 :

Fraction of inspired oxygen

MAH:

Moderate alcoholic hepatitis

Gr:

Group

HR:

Hazard ratios

CI:

Confidence intervals

C-index:

Concordance index

CRP:

C-reactive protein

EHOF:

Extrahepatic organ failure

CTP:

Child–Turcotte–Pugh

CLIF-SOFA:

Chronic liver failure-sequential organ failure assessment

NIAAA:

National Institute on Alcohol Abuse and Alcoholism

DNA:

Deoxyribonucleic acid

MAP:

Mean arterial pressure

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Acknowledgements

I would like to thank Dr Suman Pramanik and Pawan Kr. Singh for helping with the graphs and drafting of the manuscript, Mansi Singh and Ashini Kumar Hidam for retrieving the additional data.

Funding

None.

Author information

Authors and Affiliations

  1. Department of Hepatology, Institute of Liver and Biliary Sciences, D1 Vasant Kunj, New Delhi, 110070, India

    Rakhi Maiwall, Ashok Choudhury, Manoj Kumar Sharma & Shiv Kumar Sarin

  2. Department of Statistics, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, India

    Samba Siva Rao Pasupuleti

  3. Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea

    Dong Joon kim

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

    Ajit Sood, Omesh Goyal & Vandana Midha

  5. Department of Hepatology, St Johns Medical College, Bangalore, India

    Harshad Devarbhavi

  6. Department of Gastroenterology, Sir Ganga Ram Hospital and GRIPMER, Delhi, India

    Anil Arora & Ashish Kumar

  7. Department of Hepatology, IMS & SUM Hospital, Bhubaneshwar, Odisha, India

    Manoj Kumar Sahu

  8. Department of Gastroenterology, SMS Medical College, Jaipur, India

    Sudhir Maharshi

  9. Department of Hepatology, PGIMER, Chandigarh, India

    Ajay Kumar Duseja, Virendra Singh & Sunil Taneja

  10. Asian Institute of Gastroenterology, Hyderabad, India

    P. N. Rao & Anand Kulkarni

  11. Department of Hepatology, Nork Clinical Hospital of Infectious Disease, Yerevan, Armenia

    Hasmik Ghazinian

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

    Saeed Hamid

  13. Department of Hepatology, Christan Medical College, Vellore, India

    C. E. Eapen & Ashish Goel

  14. Alka Hospital, Lalitpur, Nepal

    Ananta Shreshtha

  15. Department of Hepatology, Global Hospital, Mumbai, India

    Samir Shah

  16. Department of Medicine, Military Hospital, 302, Beijing, China

    Jinhua Hu

  17. Department of Gastroenterology, VGM Hospital, Coimbatore, India

    V. G. Mohan Prasad

  18. Hebei Medical University, Shijiazhuang, China

    Nan Yuemin

  19. The Medical School of Chinese PLA, Beijing, China

    Xin Shaojie

  20. SGPGI, Lucknow, India

    R. K. Dhiman

  21. Tongji Hospital, Wuhan, China

    Tao Chen

  22. Department of Medicine, Tongji Hospital, Tongji Medical College, Wuhan, China

    Qin Ning

  23. Aster Medicity, Kochi, India

    Charles Panackel

  24. Department of Medicine, University of Kelaniya, Ragama, Sri Lanka

    Madunil A. Niriella

  25. Civil Service Hospital, Kathmandu, Nepal

    Thupten Kelsang Lama

  26. Selayang Hospital, University of Malaysia, Selangor, Malaysia

    Soek-Siam Tan

  27. Department of Medicine, Ankara University School of Medicine, Ankara, Turkey

    A. Kadir Dokmeci

  28. Seth GS Medical College and KEM Hospital, Mumbai, India

    Akash Shukla

  29. Department of Applied Mathematics and Statistics, Mizoram University (A Central University), Pachhunga University College Campus, Aizawl, India

    Samba Siva Rao Pasupuleti

Authors
  1. Rakhi Maiwall
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  2. Samba Siva Rao Pasupuleti
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  5. Ajit Sood
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  6. Omesh Goyal
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  7. Vandana Midha
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  8. Harshad Devarbhavi
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  9. Anil Arora
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  14. Virendra Singh
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  22. Ananta Shreshtha
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  23. Samir Shah
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  24. Jinhua Hu
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  25. V. G. Mohan Prasad
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  26. Nan Yuemin
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  28. R. K. Dhiman
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  29. Tao Chen
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  30. Qin Ning
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  31. Charles Panackel
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  32. Madunil A. Niriella
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  33. Thupten Kelsang Lama
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  34. Soek-Siam Tan
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  35. A. Kadir Dokmeci
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  36. Akash Shukla
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  37. Manoj Kumar Sharma
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  38. Shiv Kumar Sarin
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Contributions

RM and SKS: made the concept and design of the study. RM: wrote the first draft with subsequent inputs by SSP, and SSP performed. SKS: Statistical analysis. All other authors contributed to the patients and approved the final version of the manuscript. Critical revision of the manuscript for important intellectual comments by SKS.

Corresponding author

Correspondence to Shiv Kumar Sarin.

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Maiwall, R., Pasupuleti, S.S.R., Choudhury, A. et al. AARC score determines outcomes in patients with alcohol-associated hepatitis: a multinational study. Hepatol Int 17, 662–675 (2023). https://doi.org/10.1007/s12072-022-10463-z

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