Short-term Survival in Acutely Decompensated Cirrhotic Patients

ADS: Acute Decompensation Score; AST: Aspartate Aminotransferase; ALT: Alanine Aminotransferase; AUROC: Area Under the ROC Curve; GGT: Gamma-Glutamyl Transpeptidase; iMELD: Integrated Model for End-stage Liver Disease Model; INR: International Normalized Ratio for Prothrombin Time; LR: Likelihood Ratio; MARS: Molecular Adsorbent Recirculating System; MELD: Model for End-stage Liver Disease; MELD-Na: Model for End-stage Liver Disease-sodium score; MESO Index: Model for End-stage Liver Disease to Sodium; NPV: Negative Predictive Value; OLT: Orthotopic Liver Transplantation; PPV: Positive Predictive Value; ROC: Receiver Operating Characteristic; S: Sensitivity; SMT: Standard Medical Therapy; SOFA: Sepsis-related Organ Failure Assessment; Sp: Specificity

Introduction

Patients with previously stable chronic liver disease often develop an acute deterioration in their liver function following a precipitating event, liver-related or not. This clinical pattern is often reported as Acute-on-Chronic Liver Failure : ACLF : 2. The most frequent and severe consequences of the acute decompensation are: hepatorenal syndrome : HRS, severe hepatic encephalopathy : HE, grade II or more, organ failure : other than the liver and, finally, multiple organ dysfunction; leading to death in 50 to 90% of these population.

Up to now, orthotopic liver transplantation: OLT provides the only possible curative therapy for patients achieving this extremely severe liver dysfunction. Unfortunately, the precipitants leading to the acute deterioration: infection, acute bleeding, acute renal failure, surgical procedures, etc. often contraindicate an emergency liver transplantation.

Artificial liver support has been postulated as an effective therapy to bridge patients developing acute deterioration of cirrhosis to OLT in safe conditions. Unfortunately, studies on the efficacy of albumin dialysis failed to demonstrate a beneficial effect of this therapy in the survival of the overall population of cirrhotic patients studied. However, it seems plausible that some selected populations of ACLF patients, such as those at high-risk of death, would benefit from these new and expensive liver-support therapies.