Population-representative Incidence of Acute-On-Chronic Liver Failure: A Prospective Cross-Sectional Study

Abstract

Background: Acute-on-chronic liver failure (ACLF) is a major cause of hepatic death in the world, but no population-based studies have evaluated the incidence of ACLF. This study was conducted to determine the incidence and short-term outcomes of ACLF in a region of Eastern China.

Methods: In this prospective cross-sectional study, we collected data from public hospitals in Nantong city between January 1, 2005, and December 31, 2014. All hospitals with admission potential for ACLF patients were included. The primary outcome was ACLF defined as severe jaundice and coagulopathy with underlying chronic liver disease, according to diagnostic and laboratory criteria suggested by Chinese Society for Hepatology (CSH).

Results: During the 10-year period, a consecutive sample of 1934 ACLF patients was included in this study. The overall ACLF incidence rate over the 10-year period was 2.53 (95% confidence interval, 2.16-2.91) per 100,000 population per year, decreasing from 3.35 in 2005 to 2.06 in 2014. Chronic hepatitis B virus (HBV) infection was the leading cause of chronic liver disease and HBV reactivation was the most common cause of acute hepatic event. The 28-day mortality for the ACLF patients had a clear decline during the study period, form 50.39% in 2005 to 35.44% in 2014.

Conclusions: In the Eastern China population, the incidence of ACLF is decreasing and the prognosis improving. Short-term mortality was associated with the presence of cirrhosis and growing age. While ACLF remains a life-threatening disorder, our findings suggest that nationwide and long-term cohorts should be conducted for the natural history of ACLF.

FIGURE 1

Flow chart of study patients. ACLF indicates acute-on-chronic liver failure; ALF, acute liver failure; CLIF, chronic liver failure; HCC, hepatocellular carcinoma; PTA, prothrombin activity; TBiL, total bilirubin.

FIGURE 2

Incidence rates of acute-on-chronic liver failure (ACLF) in Nantong, China 2005 to 2014. A, Sex-standardized incidence rates (SIR) of ACLF. B, Age-specific and sex-specific incidence rates computed in 5-year age groups.

FIGURE 3

Etiology of chronic liver diseases (A) and profile of acute events (B) in the ACLF patients. AAC indicates active alcoholic consumption; AILD, autoimmune liver disease; ALD, alcoholic liver disease; DILI, drug-induced liver injury; HBV, hepatitis B virus; HCV, hepatitis C virus; NA, nucleos(t)ide analogs.

FIGURE 4

Short-term mortality rates of acute-on-chronic liver failure (ACLF) in Nantong, China 2005 to 2014. A, Short-term mortality rates in cirrhotic or noncirrhotic patients with ACLF. B, Age-adjusted and sex-adjusted mortality rates computed in 5-year age groups.