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.

Assessing the prognosis of cirrhotic patients in the intensive care unit:What we know and what we need to know better

Critically ill cirrhotic patients have high in-hospital mortality and utilize significant health care resources as a consequence of the need for multiorgan support.Despite this fact,their mortality has decreased in recent decades due to improved care of critically ill patients.Acute-on-chronic liver failure(ACLF),sepsis and elevated hepatic scores are associated with increased mortality in this population,especially among those not eligible for liver transplantation.No score is superior to another in the prognostic assessment of these patients,and both liver-specific and intensive care unit-specific scores have satisfactory predictive accuracy.The sequential assessment of the scores,especially the Sequential Organ Failure Assessment(SOFA)and Chronic Liver Failure Consortium(CLIF)-SOFA scores,may be useful as an auxiliary tool in the decision-making process regarding the benefits of maintaining supportive therapies in this population.A CLIF-ACLF>70 at admission or at day 3 was associated with a poor prognosis,as well as SOFA score>19 at baseline or increasing SOFA score>72.Additional studies addressing the prognostic assessment of these patients are necessary.

Hypoalbuminemia: an underestimated, vital characteristic of hospitalized COVID-19 positive patients?

The COVID-19 pandemic has led to the greatest worldwide health crisis in decades.The number of infected patients with severe SARS-CoV-2(COVID-19)disease has overwhelmed the capacity of almost all health care systems around world.Hypoalbuminemia has now been reported in patients with severe disease seeking help in the emergency room because of COVID-19 infection.In the past,hypoalbuminemia was considered to be a negative prognostic marker,not only in patients with chronic liver disease,but also in patients with SARS and MERS infections.Albumin is the major serum protein synthesized by the liver.A low serum albumin level is an ominous clinical sign.Introduction of amino acids to a patient's diet is of fundamental importance to hepatic albumin synthesis in different clinical situations.This highlights the importance of nutritional support during the early phases of COVID-19-infection.Furthermore,albumin synthesis in the hepatocyte is downregulated at a pretranslational level by the direct interaction of the major acute-phase cytokines which are released into the circulation during the cytokine"storm"induced by the viral effects on the lungs.Both mechanisms contribute to severe hypoalbuminemia which,combined with massive fluid losses due to the fever,is responsible for severe hypovolemia and shock commonly observed in patients with COVID-19 in critical care settings.