External validation of Chronic Liver Failure-Consortium Acute Decompensation score in the risk stratification of cirrhotic patients hospitalized with acute variceal bleeding.

Acute variceal bleeding (AVB) is a serious life-threatening complication of cirrhosis. This study aimed to validate the predictive value of Chronic Liver Failure-Consortium Acute Decompensation score (CLIF-C ADs) in the risk stratification of cirrhotic patients hospitalized with AVB. A total of 235 cirrhotic patients with AVB and without acute-on-chronic liver failure (ACLF) were retrospectively enrolled. The discrimination, calibration, overall performance and clinical utility of CLIF-C AD were evaluated and compared with traditional prognostic scores. The area under the receiver operating characteristics curve of CLIF-C AD was significantly or numerically higher than that of Child-Turcotte-Pugh (CTP) (0.871 vs. 0.737, P  = 0.03), Model for End-stage Liver Disease (MELD) (0.871 vs. 0.757, P  = 0.1) and MELD-Sodium (MELD-Na) (0.871 vs. 0.822, P  = 0.45). The calibration of CLIF-C AD was excellent and superior to that of CTP, MELD and MELD-Na. The brier score/ R2 value for CLIF-C AD, CTP, MELD and MELD-Na were 0.045/0.278, 0.051/0.090, 0.050/0.123 and 0.046/0.207, respectively, suggesting a superior overall performance of CLIF-C AD to traditional scores. In decision curve analysis, the standardized net benefit of CLIF-C AD was higher to that of traditional scores. Patients with CLIF-C ADs ≤48, 49-59 and ≥60 were, respectively, stratified into low, moderate and high-risk groups (6-week mortality: 2.7% vs. 12.5% vs. 37.5%, P  < 0.001). The prediction performance and clinical utility of CLIF-C AD for 6-week mortality in cirrhotic patients with AVB and without ACLF are excellent and superior to traditional prognostic scores. The new risk stratification with CLIF-C ADs may be useful in guiding rational management of AVB.

Zhu Z ，Jiang H 《-》

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

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. 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. 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. 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.

Zhu Z ，Jiang H 《BMC GASTROENTEROLOGY》

Chronic liver failure-consortium acute-on-chronic liver failure and acute decompensation scores predict mortality in Brazilian cirrhotic patients.

Picon RV ，Bertol FS ，Tovo CV ，de Mattos ÂZ ... -  《-》

Risk Stratification Based on Chronic Liver Failure Consortium Acute Decompensation Score in Patients With Child-Pugh B Cirrhosis and Acute Variceal Bleeding.

Optimal candidates for early transjugular intrahepatic portosystemic shunt (TIPS) in patients with Child-Pugh B cirrhosis and acute variceal bleeding (AVB) remain unclear. This study aimed to test the hypothesis that risk stratification using the Chronic Liver Failure Consortium Acute Decompensation score (CLIF-C ADs) may be useful to identify a subgroup at high risk of mortality or further bleeding that may benefit from early TIPS in patients with Child-Pugh B cirrhosis and AVB. We analyzed the pooled individual data from two previous studies of 608 patients with Child-Pugh B cirrhosis and AVB who received standard treatment between 2010 and 2017 in China. The concordance index values of CLIF-C ADs for 6-week and 1-year mortality (0.715 and 0.708) were significantly better than those of active bleeding at endoscopy (0.633 [P < 0.001] and 0.556 [P < 0.001]) and other prognostic models. With X-tile software identifying an optimal cutoff value, patients were categorized as low risk (CLIF-C ADs <48), intermediate risk (CLIF-C ADs 48-56), and high risk (CLIF-C ADs >56), with a 5.6%, 16.8%, and 25.4% risk of 6-week death, respectively. Nevertheless, the performance of CLIF-C ADs for predicting a composite endpoint of 6-week death or further bleeding was not satisfactory (area under the receiver operating characteristics curve [AUC], 0.588). A nomogram incorporating components of CLIF-C ADs and albumin, platelet, active bleeding, and ascites significantly improved the prediction accuracy (AUC, 0.725). In patients with Child-Pugh B cirrhosis and AVB, risk stratification using CLIF-C ADs identifies a subgroup with high risk of death that may derive survival benefit from early TIPS. With improved prediction accuracy for 6-week death or further bleeding, the data-driven nomogram may help to stratify patients in randomized trials. Future external validation of these findings in patients with different etiologies is required.

Lv Y ，Wang Z ，Li K ，Wang Q ，Bai W ，Yuan X ，Yu T ，Niu J ，Yang Z ，Zhu X ，Zhao J ，Xue H ，Jiang Z ，Zhuge Y ，Zhang C ，Sun J ，Ding P ，Ren W ，Li Y ，Zhang K ，Zhang W ，Guo W ，Luo B ，Li X ，Yuan J ，Han N ，Zhu Y ，He C ，Yin Z ，Fan D ，Han G ... -  《-》

Validation of the prognostic models in acute-on-chronic liver failure precipitated by hepatic and extrahepatic insults.

Maipang K ，Potranun P ，Chainuvati S ，Nimanong S ，Chotiyaputta W ，Tanwandee T ，Charatcharoenwitthaya P ... -  《PLoS One》