Objective The definition of acute-on-chronic liver failure (ACLF) based on cirrhosis, irrespective of aetiology, remains controversial. This study aimed to clarify the clinicopathological characteristics of patients with hepatitis B virus-related ACLF (HBV-ACLF) in a prospective study and develop new diagnostic criteria and a prognostic score for such patients.
Design The clinical data from 1322 hospitalised patients with acute decompensation of cirrhosis or severe liver injury due to chronic hepatitis B (CHB) at 13 liver centres in China were used to develop new diagnostic and prognostic criteria.
Results Of the patients assessed using the Chronic Liver Failure Consortium criteria with the exception of cirrhosis, 391 patients with ACLF were identified: 92 with non-cirrhotic HBV-ACLF, 271 with cirrhotic HBV-ACLF and 28 with ACLF with cirrhosis caused by non-HBV aetiologies (non-HBV-ACLF). The short-term (28/90 days) mortality of the patients with HBV-ACLF were significantly higher than those of the patients with non-HBV-ACLF. Total bilirubin (TB) ≥12 mg/dL and an international normalised ratio (INR) ≥1.5 was proposed as an additional diagnostic indicator of HBV-ACLF, and 19.3% of patients with an HBV aetiology were additionally diagnosed with ACLF. The new prognostic score (0.741×INR+0.523×HBV-SOFA+0.026×age+0.003×TB) for short-term mortality was superior to five other scores based on both discovery and external validation studies.
Conclusions Regardless of the presence of cirrhosis, patients with CHB, TB ≥12 mg/dL and INR ≥1.5 should be diagnosed with ACLF. The new criteria diagnosed nearly 20% more patients with an HBV aetiology with ACLF, thus increasing their opportunity to receive timely intensive management.
- Hepatitis B
- Liver Failure
- Liver Cirrhosis
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TW, JL and LS contributed equally.
Contributors TW, JL and LS contributed equally. The study was designed by JL and supervised by JL and LL. The manuscript was written by JL, TW, JL and LS. The experiment and data analysis were performed by JL, TW, JL, LS, JX, LJ, QZ, DS, JJ, SS, LJ, PY, LY, YL, TL, JH, XX, JC, SH, YC, SX, ZG, ZD, TH, YW, JG, TF, CP, YC, HL, YH, QX and SL. All authors were involved in critical revision of manuscript.
Funding This work was supported by National S&T Major Project of China (2012ZX10002004-001, 2017ZX10304402-002-002), National Natural Science Foundation of China (81571818/81771996) and Zhejiang Provincial and State’s Key Project of Research and Development Plan of China (2016YFC1101303/4, 2016C01G2010737).
Competing interests None declared.
Patient consent Obtained.
Ethics approval Clinical Research Ethics Committee of the First Affiliated Hospital, Zhejiang University School of Medicine.
Provenance and peer review Not commissioned; externally peer reviewed.