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. 2022 Oct;16(5):1234-1243.
doi: 10.1007/s12072-022-10372-1. Epub 2022 Jul 18.

Acute variceal bleeding portends poor outcomes in patients with acute-on-chronic liver failure: a propensity score matched study from the APASL ACLF Research Consortium (AARC)

Sanchit Sharma #  1 , Samagra Agarwal #  1 , Anoop Saraya #  2 , Ashok Choudhury  3 , Mamun Al Mahtab  4 , Mohd Shahinul Alam  4 , Sanjiv Saigal  5 , Dong Joon Kim  6 , C E Eapen  7 , Ashish Goel  7 , Qin Ning  8 , Harshad Devarbhavi  9 , Virendra Singh  10 , Akash Shukla  11 , Saeed Hamid  12 , Jinhua Hu  13 , Soek-Siam Tan  14 , Anil Arora  15 , Manoj Kumar Sahu  16 , Mohd Rela  17 , Dinesh Jothimani  17 , P N Rao  18 , Anand Kulkarni  18 , Hashmik Ghaznian  19 , Guan Huei Lee  20 , Duan Zhongping  21 , Ajit Sood  22 , Omesh Goyal  22 , Laurentius A Lesmana  23 , Rinaldi C Lesmana  23 , Sombat Treeprasertsuk  24 , Nan Yuemin  25 , Samir Shah  26 , Han Tao  27 , V M Dayal  28 , Xin Shaojie  29 , Fazal Karim  30 , Zaigham Abbas  31 , Jose D Sollano  32 , Kemal Fariz Kalista  33 , Ananta Shreshtha  34 , Diana Payawal  35 , Masao Omata  36 , Shiv Kumar Sarin #  37 ; APASL ACLF Research Consortium (AARC) for APASL ACLF Working Party
Collaborators, Affiliations

Acute variceal bleeding portends poor outcomes in patients with acute-on-chronic liver failure: a propensity score matched study from the APASL ACLF Research Consortium (AARC)

Sanchit Sharma et al. Hepatol Int. 2022 Oct.

Abstract

Background and aims: Limited data exist regarding outcomes of acute variceal bleeding (AVB) in patients with acute-on-chronic liver failure (ACLF), especially in those with hepatic failure. We evaluated the outcomes of AVB in patients with ACLF in a multinational cohort of APASL ACLF Research Consortium (AARC).

Methods: Prospectively maintained data from AARC database on patients with ACLF who developed AVB (ACLF-AVB) was analysed. This data included demographic profile, severity of liver disease, and rebleeding and mortality in 6 weeks. These outcomes were compared with a propensity score matched (PSM) cohort of ACLF matched for severity of liver disease (MELD, AARC score) without AVB (ACLF without AVB).

Results: Of the 4434 ACLF patients, the outcomes in ACLF-AVB (n = 72) [mean age-46 ± 10.4 years, 93% males, 66% with alcoholic liver disease, 65% with alcoholic hepatitis, AARC score: 10.1 ± 2.2, MELD score: 34 (IQR: 27-40)] were compared with a PSM cohort selected in a ratio of 1:2 (n = 143) [mean age-44.9 ± 12.5 years, 82.5% males, 48% alcoholic liver disease, 55.7% alcoholic hepatitis, AARC score: 9.4 ± 1.5, MELD score: 32 (IQR: 24-40)] of ACLF-without AVB. Despite PSM, ACLF patients with AVB had a higher baseline HVPG than without AVB (25.00 [IQR: 23.00-28.00] vs. 17.00 [15.00-21.75] mmHg; p = 0.045). The 6-week mortality in ACLF patients with or without AVB was 70.8% and 53.8%, respectively (p = 0.025). The 6-week rebleeding rate was 23% in ACLF-AVB. Presence of ascites [hazard ratio (HR) 2.2 (95% CI 1.03-9.8), p = 0.026], AVB [HR 1.9 (95% CI 1.2-2.5, p = 0.03)], and MELD score [HR 1.7 (95% CI 1.1-2.1), p = 0.001] independently predicted mortality in the overall ACLF cohort.

Conclusion: Development of AVB confers poor outcomes in patients with ACLF with a high 6-week mortality. Elevated HVPG at baseline represents a potential risk factor for future AVB in ACLF.

Keywords: Acute variceal bleeding; Alcoholic hepatitis; Hepatic failure; Hepatic venous pressure gradient; Infections; Organ failure; Portal hypertension; Portal pressure; Rebleeding; Varices.

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