Establishment Of A Predictive Model For Developing Invasive Pulmonary Aspergillosis And Short-term Prognostic Analysis In HBV Related Acute-on-chronic Liver Failure

Objective:To explore the risk factors and establish a predictive model for invasive pulmonary aspergillosis(invasive pulmonary aspergillosis,IPA)in patients with HBV-ACLF,analysis the prognostic of patient.Methods:A total of 428 patients diagnosed with HBV-ACLF who were admitted to the Department of Infectious Diseases of the First Affiliated Hospital of Nanchang University from January 2017 to June 2022 were collected.According to the presence of IPA,patients were divided into IPA group(n = 58)and non-IPA group(n = 370).General information of patients,complications of liver failure,and related laboratory examinations were collected.The prognosis of all patients was observed and followed up for 90 days.The independent risk factors of IPA in HBV-ACLF patients were analyzed by multivariate logistic regression,the prediction model of IPA was established.128 HBV-ACLF patients were selected during the same period for verification.The risk factors of 90-day mortality in patients with HBV-ACLF were analyzed.The 90-day prognosis of patients with HBV-ACLF complicated IPA was analyzed.Results:Among 428 patients with HBV-ACLF,58 patients developed IPA.Underlying lung diseases,ascites,type 2 diabetes mellitus,hepatorenal syndrome,respiratory failure and glucocorticoid use were independent risk factors for IPA in patients with HBV-ACLF,while prophylactic use of voriconazole was a protective factor for IPA in patients with HBV-ACLF.The AUC(95%CI)of the model was 0.846(0.788-0.903),the cut-off value was-1.872,the sensitivity was 75.0 %,the specificity was 83.1%,and the Youden index was 0.581.The AUC of validation group was 0.877(P < 0.05),95%CI was 0.776-0.978.IPA,ascites,hepatic encephalopathy,respiratory failure and CLIF-SOFA lung score were independent risk factors of 90-day mortality in patients with HBV-ACLF.CLIF-SOFA lung score had the best predictive value for 90-day mortality risk in patients with HBV-ACLF.The survival rate in IPA group was lower than that in non-IPA group(20.69% vs 52.7%,P <0.001).The survival rate of patients without respiratory failure was higher than that with respiratory failure(53.32% vs11.76%,P<0.001).The survival rate of patients with hepatic encephalopathy was lower than that without hepatic encephalopathy(14.29% vs 62.58%,P < 0.001).The survival rate of patients with ascites was lower than that without ascites(39.65% vs58.21%,P= 0.0018).The survival rate of CLIF-SOFA lung score >1 group was significantly lower than that CLIF-SOFA lung score≤1 group(0 vs 55.05%,P <0.001).In the 90-day prognosis analysis of HBV-ACLF patients with IPA,there were statistically significant differences between two groups in underlying pulmonary diseases,Cr,hepatic encephalopathy,hepatorenal syndrome,AKI,respiratory failure,extrahepatic organ failure,and CLIF-SOFA lung score(P < 0.05).Extrahepatic organ failure and CLIF-SOFA lung score were independent risk factors of 90-day mortality in HBV-ACLF with IPA patients.The 90-day cumulative mortality in the CLIF-SOFA lung score > 1 group was significantly higher than that in the CLIF-SOFA lung score≤1 group(84.62% vs 68.42%,P < 0.001).Conclusions:Underlying lung diseases,ascites,type 2 diabetes mellitus,hepatorenal syndrome,respiratory failure and glucocorticoid use are independent risk factors for IPA in patients with HBV-ACLF,and prophylactic use of voriconazole is a protective factor for IPA in patients with HBV-ACLF.The MIPA prediction model has a good predictive value for the risk of IPA in patients with HBV-ACLF.Extrahepatic organ failure and CLIF-SOFA lung score are independent risk factors for 90-day mortality in HBV-ACLF patients with IPA.CLIF-SOFA lung score has a good predictive value for the risk of 90-day mortality in HBV-ACLF patients and HBV-ACLF complicated IPA patients.