Nobuaki Nakayama1, Hayato Uemura1, Yoshihito Uchida1, Yukinori Imai1, Tomoaki Tomiya1, Shuji Terai2, Hitoshi Yoshiji3, Takuya Genda4, Akio Ido5, Kazuaki Inoue6, Naoya Kato7, Isao Sakaida8, Masahito Shimizu9, Yasuhiro Takikawa10, Masanori Abe11, Ryuzo Abe12, Kazuaki Chayama13, Kiyoshi Hasegawa14, Ayano Inui15, Mureo Kasahara16, Hiromasa Ohira17, Atsushi Tanaka18, Hajime Takikawa18, Satoshi Mochida19. 1. Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Iruma-Gun, 38 Morohongo, Moroyama-Machi, Saitama, 350-0495, Japan. 2. Division of Gastroenterology and Hepatology, Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan. 3. Department of Gastroenterology, Nara Medical University, Nara, Japan. 4. Department of Gastroenterology, Juntendo University Shizuoka Hospital, Izunokuni, Shizuoka, Japan. 5. Department of Digestive and Life-Style Related Disease, Health Research Course, Human and Environmental Sciences, Kagoshima University Graduate School of Medical and Dental Sciences, Kagoshima, Japan. 6. Department of Gastroenterology, International University of Health and Welfare, Narita, Chiba, Japan. 7. Department of Gastroenterology, Graduate School of Medicine, Chiba University, Chiba, Japan. 8. Department of Gastroenterology, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan. 9. Department of Gastroenterology, Gifu University Graduate School of Medicine, Gifu, Japan. 10. Division of Hepatology, Department of Internal Medicine, Iwate Medical University, Morioka, Japan. 11. Department of Gastroenterology and Metabology, Ehime University Graduate School of Medicine, Matsuyama, Japan. 12. Department of Emergency and Critical Care Medicine, Chiba University Graduate School of Medicine, Chiba, Japan. 13. Collaborative Research Laboratory of Medical Innovation, Hiroshima University, Hiroshima, Japan. 14. Department of Surgery, Hepato-Biliary-Pancreatic Surgery Division, University of Tokyo, Tokyo, Japan. 15. Department of Pediatric Hepatology and Gastroenterology, Saiseikai Yokohamashi Tobu Hospital, Yokohama, Japan. 16. Transplantation Center, National Center for Child Health and Development, Tokyo, Japan. 17. Department of Gastroenterology, School of Medicine, Fukushima Medical University, Fukushima, Japan. 18. Department of Medicine, Teikyo University School of Medicine, Tokyo, Japan. 19. Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Iruma-Gun, 38 Morohongo, Moroyama-Machi, Saitama, 350-0495, Japan. smochida@saitama-med.ac.jp.
Abstract
BACKGROUND: The significance of the 2018 Japanese diagnostic criteria for acute-on-chronic liver failure (ACLF) has not yet been evaluated. METHODS: A nationwide survey was performed for patients with ACLF occurring between 2017 and 2019. Cirrhotic patients with a Child-Pugh score of 5-9 were diagnosed as having ACLF when liver failure (serum bilirubin level of ≥ 5.0 mg/dL and a prothrombin time international normalization rate [INR] of ≥ 1.5) occurred within 28 days after an acute insult. Patients who fulfilled either criterion (total serum bilirubin or INR) and/or those with indeterminate Child-Pugh scores at baseline were also enrolled. RESULTS: Among the 501 enrolled patients, 183 patients (37%) were diagnosed as having ACLF. The etiologies of the cirrhosis and acute insults were alcohol intake/abuse in 114 (62%) and 75 (41%) patients, respectively. Sixty-eight patients (37%) were also diagnosed as having severe alcoholic hepatitis. The survival rate without liver transplantation was 48% among the ACLF patients and 71% in the remaining patients (P < 0.01). A multivariate analysis revealed that the disease condition was significantly associated with mortality, with an odds ratio of 2.025 in ACLF patients relative to the remaining patients (P < 0.01), and patient age and the number of organs with functional failure were also associated with mortality among the ACLF patients. CONCLUSION: The proposed diagnostic criteria for ACLF were useful for identifying cirrhotic patients with an unfavorable outcome following acute insults. A therapeutic strategy for patients with severe alcoholic hepatitis should be established, since such patients accounted for the majority of ACLF patients.
BACKGROUND: The significance of the 2018 Japanese diagnostic criteria for acute-on-chronic liver failure (ACLF) has not yet been evaluated. METHODS: A nationwide survey was performed for patients with ACLF occurring between 2017 and 2019. Cirrhotic patients with a Child-Pugh score of 5-9 were diagnosed as having ACLF when liver failure (serum bilirubin level of ≥ 5.0 mg/dL and a prothrombin time international normalization rate [INR] of ≥ 1.5) occurred within 28 days after an acute insult. Patients who fulfilled either criterion (total serum bilirubin or INR) and/or those with indeterminate Child-Pugh scores at baseline were also enrolled. RESULTS: Among the 501 enrolled patients, 183 patients (37%) were diagnosed as having ACLF. The etiologies of the cirrhosis and acute insults were alcohol intake/abuse in 114 (62%) and 75 (41%) patients, respectively. Sixty-eight patients (37%) were also diagnosed as having severe alcoholic hepatitis. The survival rate without liver transplantation was 48% among the ACLF patients and 71% in the remaining patients (P < 0.01). A multivariate analysis revealed that the disease condition was significantly associated with mortality, with an odds ratio of 2.025 in ACLF patients relative to the remaining patients (P < 0.01), and patient age and the number of organs with functional failure were also associated with mortality among the ACLF patients. CONCLUSION: The proposed diagnostic criteria for ACLF were useful for identifying cirrhotic patients with an unfavorable outcome following acute insults. A therapeutic strategy for patients with severe alcoholic hepatitis should be established, since such patients accounted for the majority of ACLF patients.