Comparative accuracy of prognostic models for short-term mortality in acute-on-chronic liver failure patients: CAP-ACLF

Verma N 1 , Dhiman RK 2 , Singh V 1 , Duseja A 1 , Taneja S 1 , Choudhury A 3 Show all authors , Sharma MK 3 , Eapen CE 4 , Devarbhavi H 5 , Al Mahtab M 6 , Shukla A 7 , Hamid SS 8 , Jafri W 8 , Butt AS 8 , Ning Q 9 , Chen T 9 , Tan SS 10 , Lesmana LA 11 , Lesmana CRA 11 , Sahu MK 12 , Hu J 13 , Lee GH 14 , Sood A 15 , Midha V 15 , Goyal O 15 , Ghazinian H 16 , Kim DJ 17 , Treeprasertsuk S 18 , Mohan Prasad VG 19 , Dokmeci AK 20 , Sollano JD 21 , Shah S 22 , Payawal DA 23 , Rao PN 24 , Kulkarni A 24 , Lau GK 25 , Duan Z 26 , Chen Y 26 , Yokosuka O 27 , Abbas Z 28 , Karim F 29 , Chowdhury D 30 , Prasad AS 31 , Sarin SK 3 , APASL ACLF Working Party

Affiliations 

  • 1 Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
  • 2 Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, 226014, India. rkpsdhiman@hotmail.com
  • 3 Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
  • 4 Department of Hepatology, CMC, Vellore, India
  • 5 Department of Hepatology, St John Medical College, Bangalore, India
  • 6 Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
  • 7 Department of Hepatology, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
  • 8 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
  • 9 Department of Medicine, Tongji Hospital, Tongji Medical College, Wuhan, China
  • 10 Department of Medicine, Hospital Selayang, Bata Caves, Selangor, Malaysia
  • 11 Department of Medicine, Medistra Hospital, Jakarta, Indonesia
  • 12 Department of Hepatology, IMS and SUM Hospital, Bhubaneswar, Odisha, India
  • 13 Department of Medicine, 302 Military Hospital, Beijing, China
  • 14 Department of Medicine, Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
  • 15 Department of Gastroenterology, DMC, Ludhiana, India
  • 16 Department of Hepatology, Nork Clinical Hospital of Infectious Disease, Yerevan, Armenia
  • 17 Department of Internal Medicine, Hallym University College of Medicine, Seoul, Korea
  • 18 Department of Medicine, Chulalongkorn University, Bangkok, Thailand
  • 19 Department of Gastroenterology, VGM Hospital, Coimbatore, India
  • 20 Department of Medicine, Ankara University School of Medicine, Ankara, Turkey
  • 21 Department of Medicine, University of Santo Tomas, Manila, Philippines
  • 22 Global Hospitals, Mumbai, India
  • 23 Department of Medicine, Cardinal Santos Medical Center, Metro Manila, Philippines
  • 24 Asian Institute of Gastroenterology, Hyderabad, India
  • 25 Department of Medicine, Humanity, and Health Medical Group, Hong Kong, China
  • 26 Beijing You'anmen Hospital, Translational Hepatology Institute Capital Medical University, Beijing, China
  • 27 Chiba University, Chiba, Japan
  • 28 Department of Medicine, Ziauddin University Hospital, Karachi, Pakistan
  • 29 CMOSH Medical College, Agrabad, Chittagong, Bangladesh
  • 30 Sir Salimullah Medical College, Mitford Hospital, Dhaka, Bangladesh
  • 31 Department of Hepatology, Foundation Nepal Sitapaila Height, Kathmandu, Nepal
Hepatol Int, 2021 Jun;15(3):753-765.
PMID: 34173167 DOI: 10.1007/s12072-021-10175-w

Abstract

BACKGROUND: Multiple predictive models of mortality exist for acute-on-chronic liver failure (ACLF) patients that often create confusion during decision-making. We studied the natural history and evaluated the performance of prognostic models in ACLF patients.

METHODS: Prospectively collected data of ACLF patients from APASL-ACLF Research Consortium (AARC) was analyzed for 30-day outcomes. The models evaluated at days 0, 4, and 7 of presentation for 30-day mortality were: AARC (model and score), CLIF-C (ACLF score, and OF score), NACSELD-ACLF (model and binary), SOFA, APACHE-II, MELD, MELD-Lactate, and CTP. Evaluation parameters were discrimination (c-indices), calibration [accuracy, sensitivity, specificity, and positive/negative predictive values (PPV/NPV)], Akaike/Bayesian Information Criteria (AIC/BIC), Nagelkerke-R2, relative prediction errors, and odds ratios.

RESULTS: Thirty-day survival of the cohort (n = 2864) was 64.9% and was lowest for final-AARC-grade-III (32.8%) ACLF. Performance parameters of all models were best at day 7 than at day 4 or day 0 (p  12 had the lowest 30-day survival (5.7%).

CONCLUSIONS: APASL-ACLF is often a progressive disease, and models assessed up to day 7 of presentation reliably predict 30-day mortality. Day-7 AARC model is a statistically robust tool for classifying risk of death and accurately predicting 30-day outcomes with relatively lower prediction errors. Day-7 AARC score > 12 may be used as a futility criterion in APASL-ACLF patients.

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

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