The risk factors for poor prognosis according to the clinical course after first acute decompensation in cirrhotic patients

초록

Background and aims: The acute on chronic liver failure (ACLF) is well known poor prognosis in acute decompensation (AD) of chronic liver disease or liver cirrhosis. Recently the European Foundation for the Study of Chronic Liver Failure (EF‐CLIF) consortium suggested that four clinical course within 3 months after first AD stratified the long term prognosis: stable decompensate cirrhosis (SDC), unstable decompensated cirrhosis (UDC) and pre-ACLF and ACLF. We verify the outcomes of these subgroups and analysis the initial factors for affecting these clinical course in Korean prospective cohort of AD. Method: The prospective Korean Acute-On-Chronic Liver Failure (KACLiF) cohort consisted of 1773 patients who were hospitalized with AD of CLD, including either LC or non-cirrhotic CLD, from July 2015 to August 2018. We enrolled the first AD patient on LC after excluding as followed: previous history of decompensation (n = 902), previous diagnosis of HCC (n = 26) and non LC (n = 133). After exclusion, a total of 746 patients with AD were enrolled. Patients were then closely followed up and evaluated for 3 months outcomes (liver transplantation and death) at 1 year were also recorded. Results: The subgroups consisted with SDC (n = 565), UDC (n = 29), Pre ACLF (n = 28) and ACLF n = 124). The subgroups of AD stratified the 90 days and 1-year mortality as followed. (90 days’ mortality: SDC = 5.3%, UDC = 10.3% and pre ACLF = 42.9%, 1year mortality: SDC = 13.5%, UDC = 34.5% and pre ACLF = 57.1%). And ACLF group showed favorable 90 days and 1year mortality (29.0% and 33.9%) compared with pre ACLF group. The initial factors that affected to occurrence of UDC or pre ACLF within 3 months were age [Odd ratio (OR) = 1.027, p = 0.042], non-variceal GI bleeding (OR = 3.031, p = 0.008), hepatic encephalopathy (HEP) (OR = 2.457, p = 0.033) and MELD (OR = 1.106, p < 0.001). Conclusion: The prognostic groups of EF-CLIF are also verified in Asian cohort of cirrhosis. The accumulation of hepatic injury caused by recurrent symptom and progression to ACLF after first AD cause the dismal prognosis. Specially, the symptoms of first AD which were difficult to control and easily reproducible such as non-variceal bleeding and HEP are the sign of recurrent hepatic insult and should be care for prevention from the occurrence.