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APASL, EASL criteria identify patients at highest risk for liver disease-related mortality

Roshini Claire Anthony
15 Nov 2017

Patients with acute-on-chronic liver failure (ACLF) who fulfil both APASL* and EASL** criteria have an elevated risk of liver disease-related mortality, according to a retrospective single-centre study conducted in Singapore. The findings also revealed the factors associated with a poorer prognosis.

Researchers analysed data of 458 patients admitted at National University Hospital, Singapore, between January 2004 and July 2014, 147 of whom had acute decompensation of chronic liver disease, and screened them for ACLF based on the APASL and EASL criteria. Of these, 78 patients (mean age 58 years, 75.6 percent male, 69.2 percent Chinese) were diagnosed with ACLF; 80.8, 82.1, and 62.8 percent met the APASL, EASL, and both criteria, respectively. Patients were followed up for a minimum of 3 months.

The most common causes of acute liver injury were bacterial infection (59 percent), hepatitis B flare (29.5 percent), and variceal bleeding (24.4 percent). Bacterial infection was the more likely trigger of ACLF in patients who met the EASL criteria compared with the other two causes (p=0.002), while hepatitis B flare was the more likely trigger among patients who met the APASL criteria (p=0.001).

The most common causes of chronic liver disease were hepatitis B (43.6 percent), alcoholic liver disease (20.5 percent), and cryptogenic liver disease (11.5 percent). Patients with ACLF who met the APASL criteria were more likely to have hepatitis B than those who fulfilled the EASL criteria. 

Mortality rate at admission and at 3 months were 57.7 and 61.5 percent, respectively, with ACLF patients who met both EASL and APASL criteria having a higher mortality risk at admission (67.3 percent; p=0.033) and at 3 months (71.4 percent; p=0.041). [World J Hepatol 2017;9:1133-1140]

A higher ACLF grade was associated with a higher mortality rate. Patients who only met the APASL criteria (without organ failure and ACLF grade 0) had a 0 percent mortality rate.

Factors increasing the risk for fatal outcome included older age (mean age, 60 vs 55 years; p=0.044), as well as renal (68.9 percent vs 30.3 percent; p=0.001), circulatory (63.6 percent vs 21.2 percent; p<0.0001), cerebral (37.8 percent vs 12.1 percent; p=0.012), and respiratory failure (17.8 percent vs 3 percent; p=0.044). Elevated serum creatinine, INR, and baseline amylase levels were stronger predictors of poor prognosis compared with other tests (p<0.0001, p=0.018, and p=0.026, respectively).

“CLIF-SOFA*** organ failure score, complemented by laboratory parameters … appear to be promising tools in determining the prognosis of patients with ACLF,” said the researchers.

“Early diagnosis of ACLF and identification of indicators predictive of poor outcome … will help to distinguish between patients with ACLF that would require transplantation from those that will survive with only organ support and intensive medical care and thus optimize treatment and survival,” they said.

Despite describing the same disease, the EASL and APASL criteria have some notable differences.

“APASL focuses more on signs of ascites and encephalopathy within a [4-week period] with chronic liver disease [while] EASL underlines the occurrence of organ failure in patients with cirrhosis resulting in 3-month mortality,” said the researchers, who highlighted that the two criteria are also based on diverse populations.

“In Singapore, with endemic chronic hepatitis B as the dominant chronic liver disease, coupled with a Westernized lifestyle and standard of living, understanding the mixed profiling of local ACLF patients and the prognostic factors will be important in better prevention and management of such high-risk patients,” they added.

 

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