The PREDICT study uncovers three clinical courses of acutely decompensated cirrhosis that have distinct pathophysiology

JOURNAL OF HEPATOLOGY

卷:73

Article

Trebicka, Jonel^1,2  Fernandez, Javier^1,4,5  Papp, Maria⁶  Caraceni, Paolo⁷  Laleman, Wim¹⁴  Gambino, Carmine⁸  Giovo, Ilaria⁹  Uschner, Frank Erhard²  Jimenez, Cesar¹⁰  Mookerjee, Rajeshwar¹¹  Gustot, Thierry¹²  Albillos, Agustin¹³  Banares, Rafael¹⁵  Janicko, Martin¹⁶  Steib, Christian¹⁷  Reiberger, Thomas¹⁸  Acevedo, Juan¹⁹  Gatti, Pietro²⁰  Bernal, William²¹  Zeuzem, Stefan²  Zipprich, Alexander²²  Piano, Salvatore⁸  Berg, Thomas²³  Bruns, Tony^24,37  Bendtsen, Flemming²⁵  Coenraad, Minneke²⁶  Merli, Manuela²⁷  Stauber, Rudolf²⁸  Zoller, Heinz²⁹  Ramos, Jose Presa³⁰  Sole, Cristina^4,5  Soriano, German^31,32  de Gottardi, Andrea^33,34  Gronbaek, Henning³⁵  Saliba, Faouzi³⁶  Trautwein, Christian³⁷  Ozdogan, Osman Cavit³⁸  Francque, Sven³⁹  Ryder, Stephen^40,41  Nahon, Pierre^42,43,44  Romero-Gomez, Manuel⁴⁵  Van Vlierberghe, Hans⁴⁶  Francoz, Claire^47,48  Manns, Michael⁴⁹  Garcia, Elisabet¹  Tufoni, Manuel⁷  Amoros, Alex¹  Pavesi, Marco¹  Sanchez, Cristina¹  Curto, Anna¹  Pitarch, Carla¹  Putignano, Antonella¹²  Moreno, Esau¹  Shawcross, Debbie²¹  Aguilar, Ferran¹  Claria, Joan^1,4,5  Ponzo, Paola⁹  Jansen, Christian³  Vitalis, Zsuzsanna⁶  Zaccherini, Giacomo⁷  Balogh, Boglarka⁶  Vargas, Victor¹⁰  Montagnese, Sara⁸  Alessandria, Carlo⁹  Bernardi, Mauro⁷  Gines, Pere^4,5  Jalan, Rajiv^1,11  Moreau, Richard^1,47,48  Angeli, Paolo^1,8  Arroyo, Vicente¹ 

[1] European Fdn Study Chron Liver Failure, EF Clif, Travesera Gracia 11,7th Floor, Barcelona 08021, Spain

[2] JW Goethe Univ Hosp, Frankfurt, Germany

[3] Univ Hosp Bonn, Bonn, Germany

[4] Hosp Clin Barcelona, IDIBAPS, Barcelona, Spain

[5] Hosp Clin Barcelona, CIBEehd, Barcelona, Spain

[6] Univ Debrecen, Fac Med, Inst Med, Dept Gastroenterol, Debrecen, Hungary

[7] Univ Bologna, Bologna, Italy

[8] Univ Padua, Dept Med, Padua, Italy

[9] Univ Torino, Citta Salute & Sci Hosp, Div Gastroenterol & Hepatol, Turin, Italy

[10] Univ Autonoma Barcelona, Hosp Vall Hebron, Liver Unit, CIBEREHD, Barcelona, Spain

[11] UCL Med Sch, Royal Free Hosp, London, England

[12] Univ Libre Bruxelles, Brussels, Belgium

[13] Univ Alcala, Hosp Univ Ramon Y Cajal, Dept Gastroenterol, CIBEREHD,IRYCIS, Madrid, Spain

[14] Univ Leuven, Leuven, Belgium

[15] Univ Complutense, Hosp Gen Univ Gregorio Maranon, Fac Med, Gastroenterol & Hepatol Dept,CIBERehd, Madrid, Spain

[16] Pavol Jozef Safarik Univ Kosice, Kosice, Slovakia

[17] Univ Hosp Munich, Dept Med 2, Munich, Germany

[18] Med Univ Vienna, Vienna, Austria

[19] Univ Hosp Plymouth NHS Trust, Plymouth, Devon, England

[20] ASL Brindisi, Intemal Med PO Ostuni, Brindisi, Italy

[21] Kings Coll Hosp London, London, England

[22] Univ Hosp Halle Wittenberg, Halle, Saale, Germany

[23] Univ Leipzig, Med Ctr, Dept Med 2, Div Hepatol, Leipzig, Germany

[24] Jena Univ Hosp, Jena, Germany

[25] Hvidovre Univ Hosp, Hvidovre, Denmark

[26] Leiden Univ, Med Ctr, Leiden, Netherlands

[27] Univ Sapienza Roma, Dept Translat & Precis Med, Rome, Italy

[28] Med Univ Graz, Graz, Austria

[29] Med Univ Innsbruck, Innsbruck, Austria

[30] CHTMAD Vila Real, Vila Real, Portugal

[31] Hosp Santa Creu & Sant Pau, Barcelona, Spain

[32] CIBERehd, Barcelona, Spain

[33] Univ Clin Visceral Surg & Med Inselspital, Bern, Switzerland

[34] Univ Svizzera Italiana, Ente Ospedaliero Cantonale, Lugano, Switzerland

[35] Aarhus Univ Hosp, Aarhus, Denmark

[36] Univ Paris Saclay, Ctr Hepatobiliaire, INSERM Unit 1193, AP HP Hop Paul Brousse, Villejuif, France

[37] Aachen Univ Hosp, Aachen, Germany

[38] Marmara Univ, Istanbul, Turkey

[39] Univ Hosp Antwerp, Antwerp, Belgium

[40] Nottingham Univ Hosp NHS Trus, NIHR Biomed Res Ctr, Nottingham, England

[41] Univ Nottingham, Nottingham, England

[42] Hop Jean Verdier, Serv Hepatol, AP HP, Bondy, France

[43] Univ Paris 13, Sorbonne Paris Cite, Equipe Labellisee Ligue Canc, St Denis, France

[44] INSERM, UMR 1162, Genom Fonct Tumeurs Sondes, Paris, France

[45] Virgen del Rocio Univ Hosp, Seville, Spain

[46] Ghent Univ Hosp, Ghent, Belgium

[47] Hop Beaujon, Serv Hepatol, APHP, Clichy, France

[48] Univ Paris, Ctr Rech LInflammat, INSERM, Paris, France

[49] Hannover Med Sch, Hannover, Germany

关键词: Chronic liver disease;    Non-elective admission;    Acute complications;    Outcome;    Risk factors;   

DOI  :  10.1016/j.jhep.2020.06.013

来源: Elsevier

【 摘 要 】

Background & Aims: Acute decompensation (AD) of cirrhosis is defined as the acute development of ascites, gastrointestinal hemorrhage, hepatic encephalopathy, infection or any combination thereof, requiring hospitalization. The presence of organ failure(s) in patients with AD defines acute-on-chronic liver failure (ACLF). The PREDICT study is a European, prospective, observational study, designed to characterize the clinical course of AD and to identify predictors of ACLF. Methods: A total of 1,071 patients with AD were enrolled. We collected detailed pre-specified information on the 3-month period prior to enrollment, and clinical and laboratory data at enrollment. Patients were then closely followed up for 3 months. Outcomes (liver transplantation and death) at 1 year were also recorded. Results: Three groups of patients were identified. Pre-ACLF patients (n = 218) developed ACLF and had 3-month and 1-year mortality rates of 53.7% and 67.4%, respectively. Unstable decompensated cirrhosis (UDC) patients (n = 233) required >= 1 readmission but did not develop ACLF and had mortality rates of 21.0% and 35.6%, respectively. Stable decompensated cirrhosis (SDC) patients (n = 620) were not readmitted, did not develop ACLF and had a 1-year mortality rate of only 9.5%. The 3 groups differed significantly regarding the grade and course of systemic inflammation (high-grade at enrollment with aggravation during follow-up in pre-ACLF; low-grade at enrollment with subsequent steady-course in UDC; and low-grade at enrollment with subsequent improvement in SDC) and the prevalence of surrogates of severe portal hypertension throughout the study (high in UDC vs. low in pre-ACLF and SDC). Conclusions: Acute decompensation without ACLF is a heterogeneous condition with 3 different clinical courses and 2 major pathophysiological mechanisms: systemic inflammation and portal hypertension. Predicting the development of ACLF remains a major future challenge. Lay summary: Herein, we describe, for the first time, 3 different clinical courses of acute decompensation (AD) of cirrhosis after hospital admission. The first clinical course includes patients who develop acute-on-chronic liver failure (ACLF) and have a high short-term risk of death - termed pre-ACLF. The second clinical course (unstable decompensated cirrhosis) includes patients requiring frequent hospitalizations unrelated to ACLF and is associated with a lower mortality risk than pre-ACLF. Finally, the third clinical course (stable decompensated cirrhosis), includes two-thirds of all patients admitted to hospital with AD - patients in this group rarely require hospital admission and have a much lower 1-year mortality risk. (C) 2020 European Association for the Study of the Liver. Published by Elsevier B.V.

【 授权许可】

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