Outcome Of Different Precipitating Events In Patients With Hepatitis B-related Acute-on-Chronic Liver Failure

Background and Aim:Acute-on-chronic liver failure(ACLF)is a complex syndrome described as the acute deterioration of liver function and accompanied by the hepatic and extrahepatic organ failures.It has high short term mortality rate and liver transplantation is the only efficient intervention in patients with irreversible conditions currently.This study aimed to clarify the precipitating events and outcome of patients with HBV-ACLF.Methods:Inpatients in the department of infectious disease of First affiliated hospital,Zhejiang University were screened,a total of 479 hospitalized ACLF patients were enrolled according to the Chinese Group on the Study of Severe Hepatitis B-ACLF(COSSH-ACLF)criteria.Patients' laboratory data,precipitating events and short term mortality were evaluated to identify their clinical characteristics and outcomes.Patients were followed up to discharge,liver transplantation or death.The precipitating events(PEs)enrolled include HBV exacerbation,infection,alcoholism,coinfection with hepatitis A virus or hepatitis E virus et al,comparing characteristic and outcomes of patients with different PEs.Results:Among patients assessed based on COSSH-ACLF criteria,single HBV exacerbation accounted for 213(44.5%)of all patients,followed by HBV exacerbation mixed with infection(49,10.2%),other major precipitating events including infection(31,6.5%),HBV exacerbation with alcoholism(21,4.4%),alcoholism(20,4.2%)and more than two precipitating events(10,2.1%).21.9%of HBV-ACLF patients don't have the identifiable PEs.liver failure was the most frequent organ failure among patients with all kinds of PEs.Analysis of patients groups in detailed categorization demonstrated that patients precipitated by HBV exacerbation and infection had higher 28-day mortality compared to patients precipitated by singles infection precipitants(45.5%vs 30.4%,p=0.024).Patients with more than 2 PEs had higher 28 day mortality compared to patients precipitated by single infection PEs(55.6%vs 21.7%,p=0.016),patients with more than 2 PEs had higher 90-day mortality compared to patients with single HBV exacerbation PEs(75%vs 41.7%,p=0.049),single alcoholism(75%vs 35.3%)or single infection PEs(75%vs 34.8%,p=0.022)?HBV-ACLF patients precipitated by HBV exacerbation had higher 28-day mortality rate compared to those without HBV exacerbation(34.4%vs.23.0%,P=0.015).Patients with HBV exacerbation and other extrahepatic PEs had higher short-term mortality compared to patients with single HBV exacerbation PEs(28 day:30.4%vs 47.2%,p=0.020;90 day:41.7%vs 61.2%,p=0.024)?Among the patients with or without cirrhosis,there are no statistical difference of PE distribution,the single HBV exacerbation account for 43.1%in cirrhotic HBV-ACLF patients and 51.9%in non-cirrhotic patients,HBV exacerbation with infection(9.5%vs 13.9%),infection(7.3%vs 2.5%),HBV exacerbation with alcoholism(4%vs 6.3%),alcoholism(4.5%vs 2.5%),more than 2 precipitants(2.3%vs 0%).Short-term mortality difference were not significant among the cirrhotic and non-cirrhotic patients under different PE categories.Conclusions:HBV exacerbation is the most prevalent precipitating event in HBV-ACLF patients and lead to higher 28-day mortality in comparison to those without HBV-exacerbation.Patients with HBV exacerbation with extrahepatic PEs have higher short-term mortality compared to patients with single HBV exacerbation PEs.The management of HBV activation is crucial for reducing high mortality rate.