The prognostic impact of each organ failure is different than that of acute-on-chronic liver failure according to the major clinical presentation in acutely decompensated cirrhosis

초록

Background and aims: The acute-on-chronic liver failure (ACLF) is major poor prognosis factor in acute decompensation (AD) of chronic liver disease (CLD) or liver cirrhosis (LC). Main pathogenic mechanism of AD has been speculated systemic inflammation and portal hypertension. The effects of not only ACLF but also each organ failure may be different depending on the major pathogenesis in AD patients, but studies for this have not yet been investigated. Therefore, we aimed to investigate whether significant differences of adverse outcomes (death or LT) show or not according to main clinical presentation in AD cirrhotic patients in prospective Korean Acute-On-Chronic Liver Failure (KACLiF) cohort. Also, we intend to reveal risk factor including ACLF and each organ failure for adverse outcomes. Method: The prospective KACLiF cohort consisted of 1773 patients who were hospitalized with AD of CLD, from July 2015 to August 2018. We enrolled a total of 1,416 patients with AD after excluding non-LC patients. Patients were then regularly evaluated for 3 months outcomes (liver transplantation and death) at 1 year were also recorded. Results: According to clinical presentation, patients were analyzed: gastrointestinal bleeding (GIB) (n = 490), ascites (n = 355), bacterial infection (n = 103), hepatic encephalopathy (HEP) (n = 178), and jaundice (n = 290). The adverse outcomes rate for subgroups of AD were differed as followed; 28-day adverse outcome (total = 8.1%, GIB = 4.9%, ascites = 9.6%, bacterial infection = 13.6%, HEp = 10.1%, and jaundice = 8.3%; p = 0.011), 90-day adverse outcome (total = 13.5%, GIB = 8.4%, ascites = 15.2%, bacterial infection = 19.4%, HEp = 17.4%, and jaundice = 15.5%; p = 0.001), and 1-year adverse outcome (total 21.9%, GIB = 14.7%, ascites = 25.1%, bacterial infection = 31.1%, HEp = 27%, and jaundice = 23.8%; p < 0.001). After multivariate cox regression analysis, MELD was most important risk factor for adverse outcome in total or subgroup of AD patients if it were analyzed with ACLF. As a result of analysis with each organ failure as a variable other than ACLF, cardiac failure in GIB patients, coagulation failure in ascites patients, coagulation failure and brain failure in BI patients, liver failure in HEP patients, and MELD and DM in jaundice patients were the main factors. Conclusion: According to main clinical presentation, cirrhotic patients with AD showed different 28-days, 90-days, and 1-year adverse outcomes. Although ACLF is a factor influencing the patient’s adverse outcomes, the relevant organ failure may differ depending on the patient’s major clinical presentation upon admission. Especially, AD patients with bacterial infection showed poorer adverse outcomes compared to patients with other clinical presentation. Each organ failure rather than ACLF tends to have a direct impact on the prognosis of cirrhotic patient with AD according to the main clinical presentation.