Incidence and Mortality of Acute on Chronic Liver Failure using Two Definitions in Patients with Compensated Cirrhosis

Abstract

Background and Aims

The term acute on chronic liver failure (ACLF) intends to identify chronic liver disease patients who develop rapid deterioration of liver function and high short‐term mortality after an acute insult. The two prominent definitions (European Association for the Study of the Liver [EASL] and Asian Pacific Association for the Study of the Liver [APASL]) differ, and existing literature applies to narrow patient groups. We sought to compare ACLF incidence and mortality among a diverse cohort of compensated cirrhotic patients, using both definitions.

Methods

Retrospective cohort study of incident compensated cirrhotic patients in the Veterans Health Administration from 2008‐2016. First ACLF events were identified for each definition. Incidence rates were computed as events per 1,000 person‐years, and mortality was calculated at 28 and 90 days.

Results

Among 80,383 cirrhotics with 3.35 years median follow‐up, 783 developed EASL and APASL ACLF, 4,296 EASL alone, and 574 APASL alone. The incidence rate of APASL ACLF was 5.7 per 1,000 person‐years (95% CI 5.4 – 6.0), and EASL ACLF was 20.1 (95% CI 19.5 – 20.6). The 28‐ and 90‐day mortalities for APASL ACLF were 41.9% and 56.1%, respectively, and for EASL ACLF were 37.6% and 50.4%. The median bilirubin at diagnosis of EASL‐alone ACLF was 2.0mg/dL (IQR 1.1‐4.0). Patients with hepatitis C or non‐alcoholic fatty liver disease had among the lowest ACLF incidence rates, but the highest short‐term mortality.

Conclusion

There is significant discordance in ACLF events by EASL and APASL criteria. The majority of patients with EASL‐alone ACLF have preserved liver function, suggesting the need for more liver‐specific ACLF criteria.

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