Introduction:
Hospitalized patients with acute decompensation (AD) of cirrhosis are at risk of progressing to acute-on-chronic liver failure (ACLF), significantly increasing their mortality. This study aimed to identify key predictors and patient trajectories predisposing to ACLF.
Methods:
In this multi-center, prospective study spanning two years, clinical, biochemical, and 90-day survival data were collected from 625 AD patients (EASL criteria) across North, South, and East India. We divided the cohort into a Derivation-cohort (DC: 318 patients) and a Validation-cohort (VC: 307 patients). Predictive models for pre-ACLF were derived, validated, and compared with established scores like MELD3.0 and CLIF-C AD.
Results:
Of 625 patients, (mean age 49, 83% male, 77.5% with alcohol-related liver disease), 32.2% progressed to ACLF. Patients progressing to ACLF showed significantly higher bilirubin (10.9vs.8.1mg/dl), leukocyte counts (9400vs.8000 per mm3), INR (1.9 vs.1.8), and MELD3.0 (28vs.25), but lower sodium (131vs.134mEq/L) and survival (62% vs.86%) compared to those without progression (p<0.05) in the DC. Consistent results were noted with AH, infection and HE as additional risk factors in VC. Liver failure at presentation [OR: 2.4 (in DC), 6.9 (in VC)] and the seven-day trajectories of bilirubin, INR, and MELD3.0 significantly predicted ACLF progression (p<0.001). A new PRE-ACLF Model showed superior predictive capability (AUC of 0.71 in DC and 0.82 in VC) compared to MELD3.0 and CLIF-C AD scores (p<0.05).
Discussion:
Approximately one-third of AD patients in this Indian cohort rapidly progressed to ACLF, resulting in high mortality. Early identification of patients at risk can guide targeted interventions to prevent ACLF.
