AARC score determines outcomes in patients with alcohol-associated hepatitis: a multinational study.

Acute-on-chronic liver failure (ACLF) is a severe form of alcoholic hepatitis (SAH). We aimed to study the natural course, response to corticosteroids (CS), and the role of the Asian Pacific Association for the Study of Liver (APASL) research consortium (AARC) score in determining clinical outcomes in AH patients. Prospectively collected data from the AARC database were analyzed. Of the 1249 AH patients, (aged 43.8 ± 10.6 years, 96.9% male, AARC score 9.2 ± 1.9), 38.8% died on a 90 day follow-up. Of these, 150 (12.0%) had mild-moderate AH (MAH), 65 (5.2%) had SAH and 1034 (82.8%) had ACLF. Two hundred and eleven (16.9%) patients received CS, of which 101 (47.87%) were steroid responders by day 7 of Lille's model, which was associated with improved survival [Hazard ratio (HR) 0.15, 95% CI 0.12-0.19]. AARC-ACLF grade 3 [OR 0.28, 0.14-0.55] was an independent predictor of steroid non-response and mortality [HR 3.29, 2.63-4.11]. Complications increased with degree of liver failure [AARC grade III vs. II vs I], bacterial infections [48.6% vs. 37% vs. 34.7%; p < 0.001); extrahepatic organ failure [66.9% vs. 41.8% vs. 35.4%; p < 0.001] respectively. The AARC score better discriminated 90-day mortality. Harrell's C-index was 0.72 compared to other scores. Nearly 4 of 5 patients with AH present with ACLF. Such patients have a higher risk of infections, organ failures, lower response to CS, and higher mortality. Patients with AH and ACLF with AARC grade 3 should be considered for an early liver transplant.

Maiwall R ，Pasupuleti SSR ，Choudhury A ，Kim DJ ，Sood A ，Goyal O ，Midha V ，Devarbhavi H ，Arora A ，Kumar A ，Sahu MK ，Maharshi S ，Duseja AK ，Singh V ，Taneja S ，Rao PN ，Kulkarni A ，Ghazinian H ，Hamid S ，Eapen CE ，Goel A ，Shreshtha A ，Shah S ，Hu J ，Prasad VGM ，Yuemin N ，Shaojie X ，Dhiman RK ，Chen T ，Ning Q ，Panackel C ，Niriella MA ，Lama TK ，Tan SS ，Dokmeci AK ，Shukla A ，Sharma MK ，Sarin SK ... -  《-》

Acute variceal bleeding portends poor outcomes in patients with acute-on-chronic liver failure: a propensity score matched study from the APASL ACLF Research Consortium (AARC).

Limited data exist regarding outcomes of acute variceal bleeding (AVB) in patients with acute-on-chronic liver failure (ACLF), especially in those with hepatic failure. We evaluated the outcomes of AVB in patients with ACLF in a multinational cohort of APASL ACLF Research Consortium (AARC). Prospectively maintained data from AARC database on patients with ACLF who developed AVB (ACLF-AVB) was analysed. This data included demographic profile, severity of liver disease, and rebleeding and mortality in 6 weeks. These outcomes were compared with a propensity score matched (PSM) cohort of ACLF matched for severity of liver disease (MELD, AARC score) without AVB (ACLF without AVB). Of the 4434 ACLF patients, the outcomes in ACLF-AVB (n = 72) [mean age-46 ± 10.4 years, 93% males, 66% with alcoholic liver disease, 65% with alcoholic hepatitis, AARC score: 10.1 ± 2.2, MELD score: 34 (IQR: 27-40)] were compared with a PSM cohort selected in a ratio of 1:2 (n = 143) [mean age-44.9 ± 12.5 years, 82.5% males, 48% alcoholic liver disease, 55.7% alcoholic hepatitis, AARC score: 9.4 ± 1.5, MELD score: 32 (IQR: 24-40)] of ACLF-without AVB. Despite PSM, ACLF patients with AVB had a higher baseline HVPG than without AVB (25.00 [IQR: 23.00-28.00] vs. 17.00 [15.00-21.75] mmHg; p = 0.045). The 6-week mortality in ACLF patients with or without AVB was 70.8% and 53.8%, respectively (p = 0.025). The 6-week rebleeding rate was 23% in ACLF-AVB. Presence of ascites [hazard ratio (HR) 2.2 (95% CI 1.03-9.8), p = 0.026], AVB [HR 1.9 (95% CI 1.2-2.5, p = 0.03)], and MELD score [HR 1.7 (95% CI 1.1-2.1), p = 0.001] independently predicted mortality in the overall ACLF cohort. Development of AVB confers poor outcomes in patients with ACLF with a high 6-week mortality. Elevated HVPG at baseline represents a potential risk factor for future AVB in ACLF.

Sharma S ，Agarwal S ，Saraya A ，Choudhury A ，Mahtab MA ，Alam MS ，Saigal S ，Kim DJ ，Eapen CE ，Goel A ，Ning Q ，Devarbhavi H ，Singh V ，Shukla A ，Hamid S ，Hu J ，Tan SS ，Arora A ，Sahu MK ，Rela M ，Jothimani D ，Rao PN ，Kulkarni A ，Ghaznian H ，Lee GH ，Zhongping D ，Sood A ，Goyal O ，Lesmana LA ，Lesmana RC ，Treeprasertsuk S ，Yuemin N ，Shah S ，Tao H ，Dayal VM ，Shaojie X ，Karim F ，Abbas Z ，Sollano JD ，Kalista KF ，Shreshtha A ，Payawal D ，Omata M ，Sarin SK ，APASL ACLF Research Consortium (AARC) for APASL ACLF Working Party ... -  《-》

Complications constitute a major risk factor for mortality in hepatitis B virus-related acute-on-chronic liver failure patients: a multi-national study from the Asia-Pacific region.

Chen T ，Yang Z ，Choudhury AK ，Al Mahtab M ，Li J ，Chen Y ，Tan SS ，Han T ，Hu J ，Hamid SS ，Huei LG ，Ghazinian H ，Nan Y ，Chawla YK ，Yuen MF ，Devarbhavi H ，Shukla A ，Abbas Z ，Sahu M ，Dokmeci AK ，Lesmana LA ，Lesmana CRA ，Xin S ，Duan Z ，Guo W ，Ma K ，Zhang Z ，Cheng Q ，Jia J ，Sharma BC ，Sarin SK ，Ning Q ... -  《-》

Identifying the early predictors of non-response to steroids in patients with flare of autoimmune hepatitis causing acute-on-chronic liver failure.

Early identification of non-response to steroids is critical in patients with autoimmune hepatitis (AIH) causing acute-on-chronic liver failure (ACLF). We assessed if this non-response can be accurately identified within first few days of treatment. Patients with AIH-ACLF without baseline infection/hepatic encephalopathy were identified from APASL ACLF research consortium (AARC) database. Diagnosis of AIH-ACLF was based mainly on histology. Those treated with steroids were assessed for non-response (defined as death or liver transplant at 90 days for present study). Laboratory parameters, AARC, and model for end-stage liver disease (MELD) scores were assessed at baseline and day 3 to identify early non-response. Utility of dynamic SURFASA score [- 6.80 + 1.92*(D0-INR) + 1.94*(∆%3-INR) + 1.64*(∆%3-bilirubin)] was also evaluated. The performance of early predictors was compared with changes in MELD score at 2 weeks. Fifty-five out of one hundred and sixty-five patients (age-38.2 ± 15.0 years, 67.2% females) with AIH-ACLF [median MELD 24 (IQR: 22-27); median AARC score 7 (6-9)] given oral prednisolone 40 (20-40) mg per day were analyzed. The 90 day transplant-free survival in this cohort was 45.7% with worse outcomes in those with incident infections (56% vs 28.0%, p = 0.03). The AUROC of pre-therapy AARC score [0.842 (95% CI 0.754-0.93)], MELD [0.837 (95% CI 0.733-0.94)] score and SURFASA score [0.795 (95% CI 0.678-0.911)] were as accurate as ∆MELD at 2 weeks [0.770 (95% CI 0.687-0.845), p = 0.526] and better than ∆MELD at 3 days [0.541 (95% CI 0.395, 0.687), p < 0.001] to predict non-response. Combination of AARC score > 6, MELD score > 24 with SURFASA score ≥ - 1.2, could identify non-responders at day 3 (concomitant- 75% vs either - 42%, p < 0.001). Baseline AARC score, MELD score, and the dynamic SURFASA score on day 3 can accurately identify early non-response to steroids in AIH-ACLF.

Sharma S ，Agarwal S ，Saraya A ，Choudhury AK ，Saigal S ，Soin AS ，Shukla A ，Sahu MK ，Lesmana LA ，Lesmana RC ，Shah SN ，Hu J ，Tan SS ，Jothimani D ，Rela M ，Ghazinyan HL ，Amrapurkar DN ，Eapen CE ，Goel A ，Payawal DA ，Hamid S ，Butt AS ，Zhongping D ，Singh V ，Duseja A ，Sood A ，Midha V ，Al Mahtab M ，Kim DJ ，Ning Q ，Kulkarni AV ，Rao PN ，Lee GH ，Treeprasertsuk S ，Shaojie X ，Karim MF ，Sollano JD ，Kalista KF ，Gani RA ，Prasad VGM ，Sarin SK ，APASL ACLF Research Consortium (AARC) for APASL ACLF working party ... -  《-》

Reversibility of acute-on-chronic liver failure syndrome in hepatitis B virus-infected patients with and without prior decompensation.

Acute-on-chronic liver failure (ACLF) is a severe clinical syndrome associated with high short-term mortality and reversibility. This study aimed to compare the characteristics of survival and reversibility in hepatitis B virus (HBV)-related ACLF (HBV-ACLF) patients with and without previous decompensation. Overall, 1044 patients who fulfilled the acute hepatic insult criteria of the APASL-ACLF Research Consortium (AARC) definition were enrolled from a prospectively established cohort of HBV-related liver failure patients. These patients were divided into the AARC ACLF group and the non-AARC ACLF group according to prior decompensation. Mortality, reversibility of ACLF syndrome, and predicted factors associated with reversibility were evaluated. Liver transplantation-free mortality of the AARC ACLF group was significantly lower than that of the non-AARC ACLF group (28 days: 28.2% vs. 40.3%, p = .012; 90 days: 41.7% vs. 65.4%, p &lt; .001). The 5-year cumulative reversal rates of ACLF syndrome were 88.0% (374/425) and 66.0% (31/47) in the AARC and non-AARC ACLF groups, respectively, (p = .039). Following reversibility of ACLF syndrome, 340/374 (90.9%) and 21/31 (67.7%) patients in the AARC and non-AARC ACLF groups, respectively, maintained a stable status within 5 years. Although prior decompensation indicated poor reversibility of ACLF syndrome, HBV-infected patients with prior decompensation who fulfilled the acute hepatic insult criteria of the AARC definition showed favourable reversibility and maintained a stable status after receiving nucleoside analogues. The AARC ACLF definition identified HBV-ACLF as a distinct syndrome with good reversibility. HBV-infected patients with prior decompensation could be included in the AARC ACLF management.

Wang H ，Tong J ，Xu X ，Chen J ，Mu X ，Zhai X ，Liu Z ，Chen J ，Liu X ，Su H ，Hu J ... -  《-》