Acute variceal bleeding portends poor outcomes in patients with acute-on-chronic liver failure: a propensity score matched study from the APASL ACLF Research Consortium (AARC)

Sharma S 1 , Agarwal S 1 , Saraya A 2 , Choudhury A 3 , Mahtab MA 4 , Alam MS 4 Show all authors , Saigal S 5 , Kim DJ 6 , Eapen CE 7 , Goel A 7 , Ning Q 8 , Devarbhavi H 9 , Singh V 10 , Shukla A 11 , Hamid S 12 , Hu J 13 , Tan SS 14 , Arora A 15 , Sahu MK 16 , Rela M 17 , Jothimani D 17 , Rao PN 18 , Kulkarni A 18 , Ghaznian H 19 , Lee GH 20 , Zhongping D 21 , Sood A 22 , Goyal O 22 , Lesmana LA 23 , Lesmana RC 23 , Treeprasertsuk S 24 , Yuemin N 25 , Shah S 26 , Tao H 27 , Dayal VM 28 , Shaojie X 29 , Karim F 30 , Abbas Z 31 , Sollano JD 32 , Kalista KF 33 , Shreshtha A 34 , Payawal D 35 , Omata M 36 , Sarin SK 37 , APASL ACLF Research Consortium (AARC) for APASL ACLF Working Party

Affiliations 

  • 1 Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India
  • 2 Department of Gastroenterology and Human Nutrition, All India Institute of Medical Sciences, New Delhi, 110029, India. ansaraya@yahoo.com
  • 3 Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
  • 4 Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
  • 5 Department of Hepatology, Medanta The Medicity, Gurgaon, India
  • 6 Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
  • 7 Department of Hepatology, Christan Medical College, Vellore, India
  • 8 Department of Medicine, Tongji Hospital, Tongji Medical College, Wuhan, China
  • 9 Department of Hepatology, St Johns Medical College, Bangalore, India
  • 10 9Department of Hepatology, PGIMER, Chandigarh, India
  • 11 LTMMC, Mumbai, India
  • 12 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
  • 13 Department of Medicine, Military Hospital, Beijing, 302, China
  • 14 Department of Medicine, Hospital Selayang, Bata Cabs, Selangor, Malaysia
  • 15 Department of Gastroenterology, Sir Ganga Ram Hospital and GRIPMER, Delhi, India
  • 16 Department of Hepatology, IMS and SUM Hospital, Bhubaneshwar, Odisha, India
  • 17 Department of Liver Transplant Surgery, Dr. Rela Institute and Medical Centre, Chennai, India
  • 18 Asian Institute of Gastroenterology, Hyderabad, India
  • 19 Department of Hepatology, Nork Clinical Hospital of Infectious Disease, Yerevan, Armenia
  • 20 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
  • 21 Translational Hepatology Institute Capital Medical University, Beijing You' an Hospital, Beijing, China
  • 22 Department of Gastroenterology, Dayanand Medical College, Ludhiana, India
  • 23 Department of Medicine, Medistra Hospital, Jakarta, Indonesia
  • 24 Department of Medicine, Chulalongkorn University, Bangkok, Thailand
  • 25 Hebei Medical University, Shijiazhuang, China
  • 26 Department of Hepatology, Global Hospital, Mumbai, India
  • 27 Tianjin Institute of Hepatobiliary Disease, Tianjin, China
  • 28 IGIMS, Patna, India
  • 29 Medical School of Chinese PLA, Beijing, China
  • 30 Department of Hepatology, Sir Salimullah Medical College, Dhaka, Bangladesh
  • 31 Department of Medicine, Ziauddin University Hospital, Karachi, Pakistan
  • 32 Department of Medicine, University of Santo Tomas, Manila, Philippines
  • 33 Division of Hepetobiliary, Cipto Mangunkusuamo Hospital, University of Indonesia, Jakarta, Indonesia
  • 34 Department of Hepatology, Foundation Nepal, Sitapaila Height, Kathmandu, Nepal
  • 35 Department of Medicine, Cardinal Santos Medical Center, Metro Manila, Philippines
  • 36 Department of Hepatology, Yamanashi Central and Kita Hospitals, University of Tokyo, Tokyo, Japan
  • 37 Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India. shivsarin@gmail.com
Hepatol Int, 2022 Oct;16(5):1234-1243.
PMID: 35851437 DOI: 10.1007/s12072-022-10372-1

Abstract

BACKGROUND AND AIMS: Limited data exist regarding outcomes of acute variceal bleeding (AVB) in patients with acute-on-chronic liver failure (ACLF), especially in those with hepatic failure. We evaluated the outcomes of AVB in patients with ACLF in a multinational cohort of APASL ACLF Research Consortium (AARC).

METHODS: Prospectively maintained data from AARC database on patients with ACLF who developed AVB (ACLF-AVB) was analysed. This data included demographic profile, severity of liver disease, and rebleeding and mortality in 6 weeks. These outcomes were compared with a propensity score matched (PSM) cohort of ACLF matched for severity of liver disease (MELD, AARC score) without AVB (ACLF without AVB).

RESULTS: Of the 4434 ACLF patients, the outcomes in ACLF-AVB (n = 72) [mean age-46 ± 10.4 years, 93% males, 66% with alcoholic liver disease, 65% with alcoholic hepatitis, AARC score: 10.1 ± 2.2, MELD score: 34 (IQR: 27-40)] were compared with a PSM cohort selected in a ratio of 1:2 (n = 143) [mean age-44.9 ± 12.5 years, 82.5% males, 48% alcoholic liver disease, 55.7% alcoholic hepatitis, AARC score: 9.4 ± 1.5, MELD score: 32 (IQR: 24-40)] of ACLF-without AVB. Despite PSM, ACLF patients with AVB had a higher baseline HVPG than without AVB (25.00 [IQR: 23.00-28.00] vs. 17.00 [15.00-21.75] mmHg; p = 0.045). The 6-week mortality in ACLF patients with or without AVB was 70.8% and 53.8%, respectively (p = 0.025). The 6-week rebleeding rate was 23% in ACLF-AVB. Presence of ascites [hazard ratio (HR) 2.2 (95% CI 1.03-9.8), p = 0.026], AVB [HR 1.9 (95% CI 1.2-2.5, p = 0.03)], and MELD score [HR 1.7 (95% CI 1.1-2.1), p = 0.001] independently predicted mortality in the overall ACLF cohort.

CONCLUSION: Development of AVB confers poor outcomes in patients with ACLF with a high 6-week mortality. Elevated HVPG at baseline represents a potential risk factor for future AVB in ACLF.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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