IMPACT OF PREVIOUS ACUTE DECOMPENSATION ON LONG-TERM MORTALITY OF ACUTE-ON-CHRONIC LIVER FAILURE

Abstract

Background: Acute-on-chronic liver failure (ACLF) is known to be associated with decreased tolerance to inflammatory response. We aimed to evaluate the impact of previous acute decompensation (AD) on the tolerance to ACLF. Methods: Cirrhosis patients who were admitted with acute deterioration in 47 academic hospitals were prospectively enrolled during 2015~2019. Patients were divided into two groups without previous AD (1st event) and with previous AD (Recurrent event) at index admission. Development of ACLF within 28 days from the enrollement were collected. Liver transplant free survival was evaluated. ACLF was defined by the EASL CLIF-C definition. Results: A total of 1,670 cirrhosis patients were enrolled and followed up for 6.8±9.3 months (Range 0-51). The prevalence of ACLF was 18.3% and the incidence was 5.4% in a month. Among the 396 patients with prevalent and incident ACLF, three fourths of patients were male and their mean age was 55±11 years. The most common etiology was alcohol (72.5%) and the most common precipitating factor was also active alcoholism (47.7%). Patients with recurrent event (n=221) were less precipitated by active alcoholism (first event, 63.4% vs. recurrent event, 35.3%, P<0.001). They were more precipiated by bacterial infection (first event, 10.9% vs. recurrent event, 18.1%, P=0.048). Patients with recurrent event had significantly lower value of serum bilirubin, and lower MELD score at baseline, at 7 days, and at ACLF episode. But WBC count and C-reactive protein were not different between two groups. Mean survival of ACLF patients were not different between those with first event (22.3 months) and recurrent event (15.8 months). Those were not different when they were compared in various subgroups based on grades of ACLF. Patients who died within 28 days were more likely to be acutely deteriorated by chronic viral hepatitis. However, the presence of recurrent event were not different between those who survived and died within 28 days after ACLF development. Predictor of long-term mortality among patients with ACLF were older age, and grade 3 (over grade 1 and 2). Presence of prior acute decompensation was not a predictive factor in these patients. Conclusion: Korean ACLF cohort based on CLIF-C definition was predominantly caused by alcohol (>70%). Active alcoholism, not the bacterial infection was the most common precipitating factor. Patients with recurrent acute decompensation had better MELD score and showed no difference of inflammatory markers and CLIF-C OF score when compared to those with patients with first event. Only the age and severity of organ failure affected mortality. Therefore, patients with previous acute decompensating event may tolerate ACLF better. However, presence of previous acute decompensating event is not an independent factor for long-term mortality at any severity of ACLF.