Impact of Onset Time, Number, Type, and Sequence of Extrahepatic Organ Failure on Prognosis of Acute-on-chronic Liver Failure

Background and Aims:The impact of the characteristics of extrahepatic organ failure(EHOF)including the onset time,number,type,and sequence on the prognosis of acute-onchronic liver failure(ACLF)patients remains unknown.This study aimed to identify the association between the characteristics of EHOF and the prognosis of ACLF patients.Methods:ACLF subjects enrolled at six hospitals in China were included in the analysis.The risk of mortality based on the characteristics of EHOF was evaluated.Survival of study groups was compared by Kaplan–Meier analysis and log-rank tests.Results:A total of 736 patients with ACLF were included.EHOF was observed in 402 patients(54.6%),of which 295(73.4%)developed single EHOF(SEHOF)and 107(26.6%)developed multiple EHOF(MEHOF).The most commonly observed EHOF was coagulation failure(47.0%),followed by renal(13.0%),brain(4.9%),respiratory(4.3%),and circulatory(2.3%)failure.Survival analysis found that MEHOF or SEHOF patients with brain failure had a worse prognosis.However,no significant outcome was found in the analysis of the effect of onset time and sequence of failed organs on prognosis.Patients were further divided into three risk subgroups by the EHOF characteristics.Kaplan–Meier analysis showed that risk stratification resulted in the differentiation of patients with different risks of mortality both in the training and validation cohorts.Conclusions:The mortality of ACLF patients was determined by the number and type,but not the onset time and sequence of EHOF.Risk stratification applicable to clinical practice was established.

Development of a Widely Applicable and Simple Prognostic Score for Patients with Acute-on-chronic Liver Failure

Background and Aims:Acute-on-chronic liver failure(ACLF)tends to progress rapidly with high short-term mortality.We aimed to create a widely applicable,simple prognostic(WASP)score for ACLF patients.Methods:A retrospective cohort of ACLF cases recruited from three centers in China were divided into training and validation sets to develop the new score.A prospective longitudinal cohort was recruited for further validation.Results:A total of 541 cases were included in the training set,and seven independent ACLF prognostic factors were screened to construct a new quantitative WASP-ACLF table.In the validation set of 671 cases,WASP-ACLF showed better predictive ability for 28-day and 90-day mortality than the currently used prognostic scores at baseline,day 3,week 1,and week 2.The predictive efficacy and clinical validity of the model improved over time.Patients were assigned to low-,intermediate-,and high-risk groups by their WASP-ACLF scores.Compared with the other two groups,intermediate-risk patients had a more uncertain prognosis,with a 90-day mortality of 44.4–50.6%.Sequential assessments at weeks 1 and 2 found the 90-day mortality of intermediate-risk groups was<20%forpatients with a≥2 point decrease in WASP-ACLF and was up to 56%for patients with a≥2 points increase.Similar results were observed in prospective data.Conclusions:The new ACLF prognostic score was simple,widely applicable,and had good predictive efficacy.Continuous assessments and trend of change in WASP-ACLF need to be considered,especially for intermediate-risk patients.