Abbreviations
ADS:
Acute Decompensation Score; AST:
Aspartate Aminotransferase; ALT: Alanine Aminotransferase; AUROC: Area
Under the ROC Curve; GGT: Gamma-Glutamyl Transpeptidase; iMELD: Integrated
Model for End-stage Liver Disease Model; INR: International Normalized Ratio
for Prothrombin Time; LR: Likelihood Ratio; MARS: Molecular Adsorbent
Recirculating System; MELD: Model for End-stage Liver Disease; MELD-Na: Model
for End-stage Liver Disease-sodium score; MESO Index: Model for End-stage Liver
Disease to Sodium; NPV: Negative Predictive Value; OLT: Orthotopic Liver
Transplantation; PPV: Positive Predictive Value; ROC: Receiver Operating
Characteristic; S: Sensitivity; SMT: Standard Medical Therapy; SOFA:
Sepsis-related Organ Failure Assessment; Sp: Specificity
Introduction
Patients
with previously stable chronic liver disease often develop an acute deterioration
in their liver function following a precipitating event, liver-related or not.
This clinical pattern is often reported as Acute-on-Chronic
Liver Failure : ACLF : 2. The most frequent and severe consequences of the
acute decompensation are: hepatorenal syndrome : HRS, severe hepatic
encephalopathy : HE, grade II or more, organ failure : other than the liver
and, finally, multiple organ dysfunction; leading to death in 50 to 90% of
these population.
Up
to now, orthotopic
liver transplantation: OLT provides the only possible curative therapy for
patients achieving this extremely severe liver dysfunction. Unfortunately, the
precipitants leading to the acute deterioration: infection, acute bleeding,
acute renal failure, surgical procedures, etc. often contraindicate an
emergency liver transplantation.
Artificial
liver support has been postulated as an effective therapy to bridge patients
developing acute deterioration of cirrhosis to OLT in safe conditions.
Unfortunately, studies on the efficacy of albumin dialysis failed to
demonstrate a beneficial effect of this therapy in the survival of the overall
population of cirrhotic patients studied. However, it seems plausible that some
selected populations of ACLF patients, such as those at high-risk of death, would
benefit from these new and expensive liver-support therapies.
The
MELD score has been developed as a predictor of early: 3-month mortality in
patients after Trans jugular intrahepatic portosystemic shunt. Actually, a
slightly modified MELD score is used all over the world to allocate patients in
liver transplant list since 2002. Several attempts have been done to improve
the prognostic accuracy of the MELD score, including the recently introduced
MELD-Na, iMELD and MESO index which
incorporate serum sodium to the originally described MELD score. Regarding
these prognostic scores, two main considerations have to be done: first, we
don’t known for sure its prognostic accuracy in a period of time shorter than 3
months, and we know that most of our acutely decompensated patients will die
within this period; and second, these scores were initially developed to assess
the survival prognosis in populations significantly different from patients
developing severe liver dysfunction following a precipitating event, who hardly
ever could be considered for immediate liver transplantation.
A
recent study identified a new score, the CLIF-C ADs, as a prognostic score for
28-day survival in ACLF patients.This score resulted more accurate than MELD in
this setting. However, whereas hepatologists are very familiar with MELD score,
the knowledge and using of this newly introduced score is scarce.
grt
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