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Clinical differences between HBV and alcohol related ACLF in a WGO classification multicenter study
Qian Zhang1,2, Jiaxuan Hu1,3, Shaotian Qiu1,3
1Department of Gastroenterology and Hepatology, Tianjin Union Medical Center, The First Affiliated Hospital of Nankai University, 190 Jieyuan Road, Hongqiao District, Tianjin, 300121, China.
Insights
Acute-on-chronic liver failure (ACLF) differs by cause, with alcohol-related ACLF showing more inflammation and organ failure than hepatitis B virus (HBV)-related ACLF. Outcomes depend on chronic liver disease severity, not just the cause.
Area of Science:
- Hepatology
- Internal Medicine
- Clinical Research
Background:
- Acute-on-chronic liver failure (ACLF) presents with significant etiological variations globally, notably hepatitis B virus (HBV)-related ACLF in China and alcohol-related ACLF in Western countries.
- Understanding these etiological differences is crucial for effective patient management and outcome prediction.
Purpose of the Study:
- To systematically compare the clinical profiles and outcomes of HBV-related ACLF versus alcohol-related ACLF.
- To stratify comparisons based on the World Gastroenterology Organization (WGO) classification of underlying chronic liver disease severity (A/B/C).
- To evaluate the predictive performance of different scoring systems (MELD, MELD-Na, CLIF-C ACLF, COSSH-ACLF II) in ACLF subtypes.
Main Methods:
- A multicenter retrospective study involving 659 patients with HBV-related ACLF and 296 patients with alcohol-related ACLF.
- Patients were stratified according to WGO A/B/C classification.
- Clinical data, including inflammatory markers, infection rates, organ failures, and mortality, were analyzed and compared between etiological groups and ACLF types.
Main Results:
- Alcohol-related ACLF exhibited higher systemic inflammation, bacterial infection rates, and extrahepatic organ failures compared to HBV-related ACLF.
- HBV-related ACLF showed more pronounced acute hepatocellular injury and higher MELD/MELD-Na scores.
- Etiological differences were most distinct in type C ACLF, which had the poorest clinical profiles and high mortality (>45%) regardless of cause.
- CLIF-C ACLF and COSSH-ACLF II scores demonstrated superior prediction of outcomes in type C ACLF compared to MELD and MELD-Na scores.
Conclusions:
- The etiology of ACLF and the severity of the underlying chronic liver disease significantly influence clinical presentation and outcomes.
- Type C ACLF, characterized by extensive organ failure, carries a uniformly high mortality risk irrespective of the underlying etiology.
- Tailored management strategies addressing both the ACLF etiology and the stage of chronic liver disease are essential for improving patient survival.
Abstract:
Acute-on-chronic liver failure (ACLF) exhibits etiological heterogeneity across regions, with hepatitis B virus (HBV)-related ACLF predominant in China and alcohol-related ACLF dominating Western populations. This multicenter retrospective study systematically compared clinical profiles of HBV-related (n = 659) and alcohol-related ACLF (n = 296) stratified by the World Gastroenterology Organization (WGO) A/B/C classification, reflecting underlying chronic liver disease severity. Compared to HBV-related ACLF, alcohol-related ACLF showed higher systemic inflammation (leukocytosis, neutrophilia), bacterial infection (P < 0.001), extrahepatic organ failures (single-organ: renal, brain and respiratory, all P < 0.05; multi-organ: P < 0.001) and higher CLIF-C ACLF/COSSH-ACLF II scores. Conversely, HBV-related ACLF exhibited acute hepatocellular injury (elevated ALT/AST), and higher MELD/MELD-Na scores. These etiological disparities were most pronounced in type C ACLF. Despite these distinct profiles, mortality did not differ between etiologies. Type C ACLF demonstrated poorest profiles and uniformly high 90-day mortality (> 45%) regardless of etiology driven by cumulative organ failure burden. Importantly, CLIF-C ACLF and COSSH-ACLF II scores outperformed MELD and MELD-Na scores in predicting outcomes for type C patients. These findings underscore the critical influence of diverse etiologies and severity stages of underlying chronic liver diseases on ACLF profiles and outcomes, thereby necessitating stratified management approaches tailored to underlying chronic liver disease to ultimately improve patient outcomes.
