Clinical Study On Acute-on-Chronic Liver Failure With Different Types

Objective:To study the clinical occurrence,development and prognosis in different types of patients with acute-on-chronic liver failure.Methods:We retrospectively collected and analyzed clinical data from 480 patients fulfilling the APASL criteria for ACLF based on hepatitis B virus(HBV)and alcohol-related chronic liver disease who were admitted to Tianjin Third Central Hospital from March 2007 to September 2017.480 patients in the study were divided into three types based on the severity of underlying liver disease.Type A was non-cirrhotic patients,type B was cirrhotic patients without previous decompensated histories and type C was cirrhotic patients with previous decompensated histories.The study compared the clinical characteristics among three types.Finally,the scores of evaluation scoring systems in three types were compared.Results:Among the 480 eligible patients,49 cases were type A,212 cases were type B and 219 cases were type C.Baseline characteristics of three groups:Type A was mostly associated with HBV related ACLF,while alcohol-related ACLF was more common in type B and C(p<0.001).Hb,PLT,HCT,ALT,AST,CHE,Na~+and AFP showed decreasing trends in three groups.Type A was the highest,type C was the lowest(p<0.05).N%,RDW,BUN,sCr showed increasing trends in three groups.Type C was the highest,type A was the lowest(p<0.05).Induced factors:The proportions of type A,B,C induced by intra-hepatic factors were 89.8%,42.9%and21%respectively(p<0.001).Type A had the highest proportion of HBV reactivation compared with type B and C.The proportions of type A,B,C induced by extra-hepatic factors were 8.2%,34.4%and 60.3%respectively(p<0.001).Type B and C had higher proportions of bacterial infection compared with type A(p<0.05 for all).Organ Failure and Prognosis:At enrollment,the rates of liver failure in type A,B and C were 65.3%,55.2%and 46.1%respectively and the rates in type A was higher than that in type C(p=0.025).There were statistically significant differences in the incidences of brain,circulation and respiratory failure among the three types(p=0.041,0.027,0.037).The rates of these organ failure were higher in type C.During hospitalization,the incidences of coagulation,circulation,brain,kidney and respiration failure were statistically different among three types(p=0.036,<0.001,0.029,<0.001,0.026).Type C was more prone to have these organ failures.The incidences of circulatory failure were gradually increased in three types(0%,3.3%,7.8%)with a statistically significant difference.In HBV related ACLF patients during hospitalization,the incidences of coagulation and renal failure in type C were higher than that in type A(p=0.047,0.004).In alcohol-related ACLF patients at enrollment,the incidence of brain failure in type C was higher than that in type B(p<0.001).The28-day and 90-day mortality of type A,B and C were statistically different.The28-day and 90-day mortality rates were highest in type C and lowest in type A(p<0.001 for all).The study of the prognostic scoring system:The prognostic value of CLIF-C ACLF score was highest in type A and B while the prognostic value of AARC-ACLF score was highest in type C.Conclusion:Type A was mostly HBV related ACLF,while alcohol-related ACLF was more common in type B and C.The primary precipitating event in type A was intra-hepatic factors and HBV reactivation was the most common type,while extra-hepatic factors were more common in type B and C especially bacterial infection.Type A was mainly based on hepatocellular injury.Type C had a limited liver reserve capacity and the basic condition was the worst which was more prone to have organ failures such as circulation,brain,kidney and respiratory failure.The28-day and 90-day mortality rates of type C were the highest,while type A were the lowest.CLIF-C ACLFs had a highest value of 90-day prognostic evaluation in type A and B.AARC-ACLFs had a highest value of 90-day prognostic evaluation in type C.