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. 2021 May;9(4):427-437.
doi: 10.1002/ueg2.12089.

Patterns of acute decompensation in hospitalized patients with cirrhosis and course of acute-on-chronic liver failure

Lorenz Balcar  1   2 , Georg Semmler  1   2 , Katharina Pomej  1   2 , Benedikt Simbrunner  1   2   3   4   5 , David Bauer  1   2 , Lukas Hartl  1   2 , Mathias Jachs  1   2 , Rafael Paternostro  1   2 , Theresa Bucsics  1   2 , Matthias Pinter  1 , Michael Trauner  1 , Mattias Mandorfer  1   2 , Thomas Reiberger  1   2   3   4   5 , Bernhard Scheiner  1   2
Affiliations

Patterns of acute decompensation in hospitalized patients with cirrhosis and course of acute-on-chronic liver failure

Lorenz Balcar et al. United European Gastroenterol J. 2021 May.

Abstract

Introduction: Recently, based on data from the PREDICT study, the European Foundation for the Study of Chronic Liver Failure (EF-CLIF) consortium proposed pathophysiological/prognostic groups in hospitalized patients with cirrhosis: stable decompensated cirrhosis (SDC), unstable decompensated cirrhosis (UDC), pre-acute-on-chronic liver failure (pre-ACLF), and ACLF. We evaluated the outcomes of these subgroups in a real-life cohort of hospitalized patients with cirrhosis.

Methods: Patients with cirrhosis developing first AD between 09/2010 and 12/2017 at the Vienna General Hospital were evaluated for this retrospective analysis.

Results: Two hundred and ten patients with cirrhosis (aged 57.6 ± 11.8 years) including n = 45 (21.4%) SDC, n = 100 (47.6%) UDC, n = 28 (13.3%) pre-ACLF, and n = 37 (17.6%) with ACLF were considered. The proposed AD subgroups discriminated between patients with favorable (1-year mortality: SDC: 6.7% and UDC: 19.6%) and dismal prognosis (90-day mortality: pre-ACLF: 42.9%). Interestingly, systemic inflammation gradually increased (e.g., C-reactive protein, SDC: 0.9 mg/dl, vs. UDC: 2.0 mg/dl vs. pre-ACLF: 3.2 mg/dl, p < 0.001) while renal function was progressively deteriorating (creatinine levels, SDC: 0.8 mg/dl vs. UDC: 0.9 mg/dl vs. pre-ACLF: 1.2 mg/dl, p < 0.001) across prognostic subgroups in patients with cirrhosis.

Discussion: The recently proposed pathophysiological/prognostic EF-CLIF subgroups are also reproduceable in a real-life cohort of cirrhotic patients. As ACLF is a common and important complication, patients at risk of pre-ACLF at index AD should be evaluated and if disease proceeds, been treated early and aggressively to avoid excessive mortality.

Keywords: ACLF; acute decompensation; acute-on-chronic liver failure; cirrhosis; natural course.

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Conflict of interest statement

The authors have nothing to disclose regarding the work under consideration for publication. The following authors disclose conflicts of interests outside the submitted work: Lorenz Balcar, Georg Semmler, Katharina Pomej, Rafael Paternostro, David Bauer, and Benedikt Simbrunner have nothing to disclose. Theresa Bucsics received travel support from Gilead, BMS, Roche, Bayer, and AbbVie. Michael Trauner received grant support from Albireo, Cymabay, Falk, Gilead, Intercept, MSD and Takeda, honoraria for consulting from AbbVie, Albireo, Boehringer Ingelheim, BiomX, Falk, Genfit Gilead, Intercept, Janssen, Novartis Regulus and Shire, speaker fees from, Falk, Gilead, Intercept and MSD as well as travel support from Abbvie, Falk, Gilead and Intercept. Mattias Mandorfer has served as a speaker and consultant for AbbVie, BMS, Gilead, Gore, and Janssen. Thomas Reiberger received speaker fees from Boehringer Ingelheim, Roche, W.L. Gore and MSD, grant support from Boehringer Ingelheim, Boston Scientific, Cook Medical, Gilead, Guerbet, Abbvie, Phenex Pharmaceuticals, Philips, W.L. Gore, and MSD, served as a consultant for Abbvie, Bayer, Boehringer Ingelheim, Gilead, Intercept and MSD and received travel support from Gilead, Roche, MSD, and Gore. Bernhard Scheiner received travel support from AbbVie, Ipsen, and Gilead.

Concept of the study: Lorenz Balcar, Mattias Mandorfer, Thomas Reiberger, and Bernhard Scheiner. Data collection: Lorenz Balcar and Bernhard Scheiner. Statistical analysis: Lorenz Balcar and Bernhard Scheiner. Drafting of the manuscript: Lorenz Balcar, Mattias Mandorfer, Thomas Reiberger, and Bernhard Scheiner. Revision for important intellectual content and approval of the final manuscript: All authors.

Figures

FIGURE 1
FIGURE 1
Study flow chart. AD, acute decompensation; ACLF, acute‐on‐chronic liver failure; FU, follow‐up; HCC, hepatocellular carcinoma; LT, liver transplantation; SDC, stable decompensated cirrhosis; UDC, unstable decompensated cirrhosis
FIGURE 2
FIGURE 2
Sankey plot indicating the short‐term (three months) course of patients with pre‐ACLF and ACLF. ACLF, acute‐on‐chronic liver failure; AD, acute decompensation
FIGURE 3
FIGURE 3
Sankey plot indicating the long‐term course of liver disease at 1 year. AD, acute decompensation; ACLF, acute‐on‐chronic liver failure; LT, liver transplantation; SDC, stable decompensated cirrhosis; UDC, unstable decompensated cirrhosis
FIGURE 4
FIGURE 4
Comparison of LT‐free survival between the different prognostic groups. ACLF, acute‐on‐chronic liver failure; LT, liver transplant; SDC, stable decompensated cirrhosis; UDC, unstable decompensated cirrhosis
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