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Acute-on-chronic liver failure grade predicts hepatorenal syndrome outcomes

Acute-on-chronic liver failure grade was a significant determinant of response to terlipressin and albumin among patients treated for type 1 hepatorenal syndrome, according to a recently published study.

ACLF also affected survival independently of response to treatment.

“The most outstanding observation of our study is that severity of ACLF, as estimated by the number of extrarenal organ failures, is an additional important factor predicting treatment response in patients with [hepatorenal syndrome (HRS)],” Salvatore Piano, MD, from the University of Padova, Italy, and colleagues wrote. “These data as well as the effects of HRS reversal on survival may have important implications for clinical practice, in particular in patients with [ACLF grade 3].”

Piano and colleagues retrospectively evaluated data of 298 patients with cirrhosis and HRS to assess the impact of ACLF severity on renal response to terlipressin and albumin in patients with HRS. The study cohort comprised 179 with ACLF grade 1, 91 with grade 2, and 28 with grade 3.

HRS resolved in 53% of the patients. Responders had significantly lower baseline serum bilirubin (3.3 vs. 4.8 mg/dL; P = .003), international normalized ratio (1.6 vs. 1.8; P = .004) and serum creatinine (2.7 vs. 3.2 mg/dL; P < .001) compared with nonresponders. Response rate decreased with advancing ACLF grade: from 60% in those with grade 1, to 48% in grade 2, to 29% in grade 3 (P < .001).

Multivariate analysis showed that baseline serum creatinine (OR = 0.23; P = .001) and ACLF grade (OR = 0.63; P = .01) were independent predictors of response to treatment.

During 90 days of follow-up, 119 patients died, 50 underwent liver transplantation, 123 completed follow-up and six patients were lost to follow-up. Ninety-day mortality incidence increased with advancing ACLF grade: from 30% in those with grade 1, to 50% in grade 2, to 79% in grade 3 (P < .001).

Multivariate analysis showed that age (HR = 1.05; 95% CI, 1.03-1.07), white blood cell count (HR = 1.51; 95% CI, 1.12-2.02), ACLF grade (HR = 2.06; 95% CI, 1.54-2.75), and response to treatment (HR = 0.41; 95% CI, 0.29-0.6) were independent predictors of 90-day mortality.

“These data indicate that the grade of systemic inflammation and the presence and number of extrarenal organ failure(s) have a great impact on the clinical course in patients with HRS,” Piano and colleagues wrote. “New treatments should be explored for patients with type 1 HRS looking at systemic inflammation as a potential target.” – by Talitha Bennett

Disclosure: Piano reports no relevant financial disclosures. Please see the full study for the other authors’ relevant financial disclosures.