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. 2023 May 12;23(1):148.
doi: 10.1186/s12876-023-02768-6.

Risk stratification based on acute-on-chronic liver failure in cirrhotic patients hospitalized for acute variceal bleeding

Zongyi Zhu  1   2 , Huiqing Jiang  3
Affiliations

Risk stratification based on acute-on-chronic liver failure in cirrhotic patients hospitalized for acute variceal bleeding

Zongyi Zhu et al. BMC Gastroenterol. .

Abstract

Background and aims: Acute variceal bleeding (AVB) is a life-threatening complication of cirrhosis. Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute decompensation of cirrhosis, multiple organ failures and high short-term mortality. This study aimed to evaluate the role of ACLF in the risk stratification of cirrhotic patients with AVB.

Methods: Prospective data of 335 cirrhotic patients hospitalized for AVB were retrospectively extracted from Medical Information Mart for Intensive Care (MIMIC)-IV database. ACLF was defined by European Association for the Study of Liver-Chronic Liver Failure Consortium and diagnosed/graded with chronic liver failure-organ failure (CLIF-OF) score. Cox-proportional hazards regression analysis was performed to identify the risk factors for 6-week morality in AVB patients. Discrimination and calibration of prognostic scores were evaluated by plotting the receiver operating characteristics (ROC) curve and calibration curve, respectively. Overall performance was assessed by calculating the Brier score and R2 value.

Results: A total of 181 (54.0%) patients were diagnosed with ACLF (grade 1: 18.2%, grade 2: 33.7%, grade 3: 48.1%) at admission. The 6-week mortality in patients with ACLF was significantly higher than that in patients without ACLF (43.6% vs. 8.4%, P < 0.001) and increased in line with the severity of ACLF (22.5%, 34.2% and 63.8% for ACLF grade 1, 2 and 3, P < 0.001). In multivariate analysis, presence of ACLF remained as an independent risk factor for 6-week mortality after adjusting for confounding factors (HR = 2.12, P = 0.03). The discrimination, calibration and overall performance of CLIF-C ACLF and CLIF-C AD were superior to the traditional prognostic scores (CTP, MELD and MELD-Na) in the prediction of 6-week mortality of patients with and without ACLF, respectively.

Conclusion: The prognosis of cirrhotic patients with AVB is poor when accompanied by ACLF. ACLF at admission is an independent predictor for the 6-week mortality in cirrhotic patients with AVB. CLIF-C ACLF and CLIF-C AD are the best prognostic scores in AVB patients with and without ACLF, respectively, and can be used for the risk stratification of these two distinct entities.

Keywords: Acute variceal bleeding; Acute-on-chronic liver failure; Prognosis; Risk stratification.

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Conflict of interest statement

The authors declare that they have no competing interests.

Figures

Fig. 1
Fig. 1
Cumulative survival rates of cirrhotic patients hospitalized for AVB. A The 42-day cumulative survival rate of ACLF patients was significantly lower than that of AD patients (56.4% vs. 91.6%, P < 0.001). B The 42-day cumulative survival rate of patients with ACLF gradually decreases with the increase of ACLF grade (P < 0.001)
Fig. 2
Fig. 2
Forest plot showing the risk factors for 6-week mortality in cirrhotic patients with AVB. MAP, mean arterial pressure; SPO2, percutaneous oxygen saturation; FIO2, fraction of inspired oxygen
Fig. 3
Fig. 3
Discrimination performance of prognostic scores in ACLF A and AD patients B
Fig. 4
Fig. 4
Calibration performance of prognostic scores in ACLF A and AD patients B
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References

    1. Reverter E, Tandon P, Augustin S, Turon F, Casu S, Bastiampillai R, et al. A MELD-based model to determine risk of mortality among patients with acute variceal bleeding. Gastroenterology. 2014;146(2):412–419. doi: 10.1053/j.gastro.2013.10.018. - DOI - PubMed
    1. Fortune BE, Garcia-Tsao G, Ciarleglio M, Deng Y, Fallon MB, Sigal S, et al. Child-Turcotte-Pugh Class is best at stratifying risk in variceal hemorrhage: analysis of a U.S. multi-center prospective study. J Clin Gastroenterol. 2017;51(5):446–53. doi: 10.1097/MCG.0000000000000733. - DOI - PMC - PubMed
    1. de Franchis R. Expanding consensus in portal hypertension: Report of the Baveno VI consensus workshop: stratifying risk and individualizing care for portal hypertension. J Hepatol. 2015;63(3):743–752. doi: 10.1016/j.jhep.2015.05.022. - DOI - PubMed
    1. European Association for the Study of the Liver EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018;69(2):406–460. doi: 10.1016/j.jhep.2018.03.024. - DOI - PubMed
    1. Garcia-Tsao G, Abraldes JG, Berzigotti A, Bosch J. Portal hypertensive bleeding in cirrhosis: risk stratification, diagnosis, and management: 2016 practice guidance by the American association for the study of liver diseases. Hepatology. 2017;65(1):310–335. doi: 10.1002/hep.28906. - DOI - PubMed