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Clinical Trial
. 2016 Jan 20;11(1):e0146745.
doi: 10.1371/journal.pone.0146745. eCollection 2016.

Characteristics and Discrepancies in Acute-on-Chronic Liver Failure: Need for a Unified Definition

Tae Yeob Kim  1 , Do Seon Song  2 , Hee Yeon Kim  2 , Dong Hyun Sinn  3 , Eileen L Yoon  4 , Chang Wook Kim  2 , Young Kul Jung  5 , Ki Tae Suk  6 , Sang Soo Lee  7 , Chang Hyeong Lee  8 , Tae Hun Kim  9 , Jeong Han Kim  10 , Won Hyeok Choe  10 , Hyung Joon Yim  5 , Sung Eun Kim  11 , Soon Koo Baik  12 , Byung Seok Lee  13 , Jae Young Jang  14 , Jeong Suh 3rd  15 , Hyoung Su Kim  16 , Seong Woo Nam  17 , Hyeok Choon Kwon  17 , Young Seok Kim  18 , Sang Gyune Kim  18 , Hee Bok Chae  19 , Jin Mo Yang  2 , Joo Hyun Sohn  20 , Heon Ju Lee  21 , Seung Ha Park  22 , Byung Hoon Han  23 , Eun Hee Choi  24 , Chang H Kim  25 , Dong Joon Kim  6 ; Korean Acute-on-Chronic Liver Failure Study Group
Affiliations
Clinical Trial

Characteristics and Discrepancies in Acute-on-Chronic Liver Failure: Need for a Unified Definition

Tae Yeob Kim et al. PLoS One. .

Abstract

Background & aim: To investigate the prevalence, mortalities, and patient characteristics of Acute-on-chronic liver failure (ACLF) according to the AARC (Asian Pacific Association for the Study of the Liver ACLF Research Consortium) and European Association for the Study of the Liver CLIF-C (Chronic Liver Failure Consortium) definitions.

Methods: We collected retrospective data for 1470 hospitalized patients with chronic liver disease (CLD) and acute deterioration between January 2013 and December 2013 from 21 university hospitals in Korea.

Results: Of the patients assessed, the prevalence of ACLF based on the AARC and CLIF-C definitions was 9.5% and 18.6%, respectively. The 28-day and 90-day mortality rates were higher in patients with ACLF than in those without ACLF. Patients who only met the CLIF-C definition had significantly lower 28-day and 90-day survival rates than those who only met the AARC definition (68.0% vs. 93.9%, P<0.001; 55.1% vs. 92.4%, P<0.001). Among the patients who had non-cirrhotic CLD, the 90-day mortality of the patients with ACLF was higher than of those without ACLF, although not significant (33.3% vs. 6.0%, P = 0.192). Patients with previous acute decompensation (AD) within 1- year had a lower 90-day survival rate than those with AD more than 1 year prior or without previous AD (81.0% vs. 91.9% or 89.4%, respectively, all P<0.001). Patients who had extra-hepatic organ failure without liver failure had a similar 90-day survival rate to those who had liver failure as a prerequisite (57.0% vs. 60.6%, P = 0.391).

Conclusions: The two ACLF definitions result in differences in mortality and patient characteristics among ACLF patients. We suggest that non-cirrhotic CLD, previous AD within 1 year, and extra-hepatic organ failure should be included in the ACLF diagnostic criteria. In addition, further studies are necessary to develop a universal definition of ACLF.

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Conflict of interest statement

Competing Interests: The authors have declared that no competing interests exist.

Figures

Fig 1
Fig 1. Flow chart of the KACLiF study.
Abbreviations: HCC, hepatocellular carcinoma; KACLiF, Korean acute-on-chronic liver failure.
Fig 2
Fig 2. Diagram of the total enrolled patients.
(A) acute deterioration with chronic liver disease (enrolled patients) (N = 1470); (B) CLD patients without prior history of decompensation (N = 1021); (C) cirrhotic patients regardless of prior history of decompensation (N = 1352); (D) ACLF development according to the AARC definition (N = 140); (E) ACLF development according to the CLIF-C definition (N = 274); (F) ACLF development according to the AARC and CLIF-C definitions (N = 74). Abbreviations: CLD, chronic liver disease; ACLF, acute-on-chronic liver failure; AARC, Asian Pacific Association for the Study of the Liver ACLF Research Consortium; CLIF-C, Chronic liver failure consortium
Fig 3
Fig 3. Twenty-eight- and 90-day mortality of patients with ACLF.
(A) AARC definition, (B) CLIF-C definition. *One hundred sixty-three patients were lost to follow up. Abbreviations: AARC, Asian Pacific Association for the Study of the Liver ACLF Research Consortium; CLIF-C, Chronic liver failure consortium
Fig 4
Fig 4. Kaplan-Meier survival curves according to the definition of ACLF.
(A) 28-day survival and (B) 90-day survival. Abbreviations: ACLF, Acute-on-chronic liver failure; AARC, Asian Pacific Association for the Study of the Liver ACLF Research Consortium; CLIF-C, Chronic Liver Failure Consortium.
Fig 5
Fig 5. Kaplan-Meier survival curves according to the time of ACLF development.
(A) AARC definition, (B) CLIF-C definition. Abbreviations: ACLF, Acute-on-chronic liver failure; AARC, Asian Pacific Association for the Study of the Liver ACLF Research Consortium; CLIF-C, Chronic liver failure consortium
Fig 6
Fig 6. Twenty-eight- and 90-day mortality.
(A) According to the presence of cirrhosis (*15 of patients without LC and 148 patients with LC were lost to follow-up) and (B) according to the presence of ACLF (**138 of patients without ACLF and 31 patients with ACLF were lost to follow-up). Abbreviations: LC, liver cirrhosis; ACLF, acute-on-chronic liver failure
Fig 7
Fig 7. Ninety-day survival curves according to previous acute decompensation.
(A) Without previous AD vs. with previous AD and (B) without previous AD vs. AD more than 1 year prior vs. AD within 1 year. Abbreviation: AD, acute decompensation
Fig 8
Fig 8. Kaplan-Meier survival curves of ACLF according to the definition of organ failure (liver failure as a prerequisite vs. extra-hepatic organ failure).
(A) 28-day and (B) 90-day survival according to liver failure as defined by the AARC definition, (C) 28-day and (D) 90-day survival according to bilirubin level. Abbreviations: ACLF, acute-on-chronic liver failure; AARC, Asian Pacific Association for the Study of the Liver ACLF Research Consortium
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