PREDICT identifies precipitating events associated with the clinical course of acutely decompensated cirrhosis.

Acute-On-Chronic Liver Failure / blood Bacterial Infections / complications Disease Progression Europe / epidemiology Female Hepatitis, Alcoholic / complications Humans Inflammation / blood Liver Cirrhosis / epidemiology Male Medical History Taking / statistics & numerical data Middle Aged Needs Assessment Organ Dysfunction Scores Precipitating Factors Preventive Health Services / methods Prognosis

Acute complications Chronic liver disease Non-elective admission Outcome Risk factors

Journal

Journal of hepatology

ISSN: 1600-0641

Titre abrégé: J Hepatol

Pays: Netherlands

ID NLM: 8503886

Informations de publication

Date de publication:
05 2021

Historique:

received: 14 07 2020

revised: 10 11 2020

accepted: 10 11 2020

pubmed: 24 11 2020

medline: 1 2 2022

entrez: 23 11 2020

Statut: ppublish

Résumé

Acute decompensation (AD) of cirrhosis may present without acute-on-chronic liver failure (ACLF) (AD-No ACLF), or with ACLF (AD-ACLF), defined by organ failure(s). Herein, we aimed to analyze and characterize the precipitants leading to both of these AD phenotypes. The multicenter, prospective, observational PREDICT study (NCT03056612) included 1,273 non-electively hospitalized patients with AD (No ACLF = 1,071; ACLF = 202). Medical history, clinical data and laboratory data were collected at enrolment and during 90-day follow-up, with particular attention given to the following characteristics of precipitants: induction of organ dysfunction or failure, systemic inflammation, chronology, intensity, and relationship to outcome. Among various clinical events, 4 distinct events were precipitants consistently related to AD: proven bacterial infections, severe alcoholic hepatitis, gastrointestinal bleeding with shock and toxic encephalopathy. Among patients with precipitants in the AD-No ACLF cohort and the AD-ACLF cohort (38% and 71%, respectively), almost all (96% and 97%, respectively) showed proven bacterial infection and severe alcoholic hepatitis, either alone or in combination with other events. Survival was similar in patients with proven bacterial infections or severe alcoholic hepatitis in both AD phenotypes. The number of precipitants was associated with significantly increased 90-day mortality and was paralleled by increasing levels of surrogates for systemic inflammation. Importantly, adequate first-line antibiotic treatment of proven bacterial infections was associated with a lower ACLF development rate and lower 90-day mortality. This study identified precipitants that are significantly associated with a distinct clinical course and prognosis in patients with AD. Specific preventive and therapeutic strategies targeting these events may improve outcomes in patients with decompensated cirrhosis. Acute decompensation (AD) of cirrhosis is characterized by a rapid deterioration in patient health. Herein, we aimed to analyze the precipitating events that cause AD in patients with cirrhosis. Proven bacterial infections and severe alcoholic hepatitis, either alone or in combination, accounted for almost all (96-97%) cases of AD and acute-on-chronic liver failure. Whilst the type of precipitant was not associated with mortality, the number of precipitant(s) was. This study identified precipitants that are significantly associated with a distinct clinical course and prognosis of patients with AD. Specific preventive and therapeutic strategies targeting these events may improve patient outcomes.

Sections du résumé

BACKGROUND & AIMS

METHODS

The multicenter, prospective, observational PREDICT study (NCT03056612) included 1,273 non-electively hospitalized patients with AD (No ACLF = 1,071; ACLF = 202). Medical history, clinical data and laboratory data were collected at enrolment and during 90-day follow-up, with particular attention given to the following characteristics of precipitants: induction of organ dysfunction or failure, systemic inflammation, chronology, intensity, and relationship to outcome.

RESULTS

Among various clinical events, 4 distinct events were precipitants consistently related to AD: proven bacterial infections, severe alcoholic hepatitis, gastrointestinal bleeding with shock and toxic encephalopathy. Among patients with precipitants in the AD-No ACLF cohort and the AD-ACLF cohort (38% and 71%, respectively), almost all (96% and 97%, respectively) showed proven bacterial infection and severe alcoholic hepatitis, either alone or in combination with other events. Survival was similar in patients with proven bacterial infections or severe alcoholic hepatitis in both AD phenotypes. The number of precipitants was associated with significantly increased 90-day mortality and was paralleled by increasing levels of surrogates for systemic inflammation. Importantly, adequate first-line antibiotic treatment of proven bacterial infections was associated with a lower ACLF development rate and lower 90-day mortality.

CONCLUSIONS

This study identified precipitants that are significantly associated with a distinct clinical course and prognosis in patients with AD. Specific preventive and therapeutic strategies targeting these events may improve outcomes in patients with decompensated cirrhosis.

LAY SUMMARY

Acute decompensation (AD) of cirrhosis is characterized by a rapid deterioration in patient health. Herein, we aimed to analyze the precipitating events that cause AD in patients with cirrhosis. Proven bacterial infections and severe alcoholic hepatitis, either alone or in combination, accounted for almost all (96-97%) cases of AD and acute-on-chronic liver failure. Whilst the type of precipitant was not associated with mortality, the number of precipitant(s) was. This study identified precipitants that are significantly associated with a distinct clinical course and prognosis of patients with AD. Specific preventive and therapeutic strategies targeting these events may improve patient outcomes.

Identifiants

DOI: 10.1016/j.jhep.2020.11.019 PMID: 33227350

pubmed: 33227350

pii: S0168-8278(20)33772-7

doi: 10.1016/j.jhep.2020.11.019

pii:

doi:

Banques de données

ClinicalTrials.gov

['NCT03056612']

Types de publication

Journal Article Multicenter Study Observational Study Research Support, Non-U.S. Gov't

Langues

eng

Sous-ensembles de citation

Pagination

1097-1108

Investigateurs

Miriam Maschmeier (M)

David Semela (D)

Laure Elkrief (L)

Ahmed Elsharkawy (A)

Tamas Tornai (T)

Istvan Tornai (I)

Istvan Altorjay (I)

Agnese Antognoli (A)

Maurizio Baldassarre (M)

Martina Gagliardi (M)

Eleonora Bertoli (E)

Sara Mareso (S)

Alessandra Brocca (A)

Daniela Campion (D)

Giorgio Maria Saracco (GM)

Martina Rizzo (M)

Jennifer Lehmann (J)

Alessandra Pohlmann (A)

Maximilian J Brol (MJ)

Johannes Chang (J)

Robert Schierwagen (R)

Elsa Solà (E)

Nesrine Amari (N)

Miguel Rodriguez (M)

Frederik Nevens (F)

Ana Clemente (A)

Martin Janicko (M)

Daniel Markwardt (D)

Mattias Mandorfer (M)

Christoph Welsch (C)

Tanja M Welzel (TM)

Emanuela Ciraci (E)

Vish Patel (V)

Cristina Ripoll (C)

Adam Herber (A)

Paul Horn (P)

Flemming Bendtsen (F)

Lise Lotte Gluud (LL)

Jelte Schaapman (J)

Oliviero Riggio (O)

Florian Rainer (F)

Jörg Tobiasch Moritz (JT)

Mónica Mesquita (M)

Edilmar Alvarado-Tapias (E)

Osagie Akpata (O)

Luise Aamann (L)

Didier Samuel (D)

Sylvie Tresson (S)

Pavel Strnad (P)

Roland Amathieu (R)

Macarena Simón-Talero (M)

Francois Smits (F)

Natalie van den Ende (N)

Javier Martinez (J)

Rita Garcia (R)

Harald Rupprechter (H)

Cornelius Engelmann (C)

Osman Cavit Özdogan (OC)

Commentaires et corrections

Type : CommentIn

Informations de copyright

Déclaration de conflit d'intérêts

Conflict of interest None of the authors have conflicts of interest for the reported study. Please refer to the accompanying ICMJE disclosure forms for further details.