World Congress of Gastroenterology

WCOG 2019


 
VALIDATION AND COMPARISON OF AARC SCORE IN PREDICTING MORTALITY AMONG PATIENTS WITH ACLF DUE TO HEPATITIS E IN ASIA PACIFIC REGION
AMNA SUBHAN BUTT 1 SAEED HAMID ASHOK K CHOUDHURY 2 WASIM JAFRI 1 Y K CHAWLA 3 SUNIL TANEJA 3 ZAIGHAM ABBASS 4 AKASH SHUKLA 5 MAMUN AL MAHTAB 6 MD FAZAL KARIM 7 C E EAPEN 8 ASISH GOEL 8 HASMIK GHAZINIYAN 9 P N RAO 10 MANOJ K SAHU 11 SAMIR SHAH 12 CHETAN R KALAL 12 HARSHAD DEVARBHAVI 13 S S TAN 14 DIANA A PAYAWAL 15 PRIYANKA JAIN 2 IRENE PAULSON 2 S K SARIN 2

1- AGA KHAN UNIVERSITY HOSPITAL, KARACHI, PAKISTAN
2- 2. INSTITUTE OF LIVER AND BILIARY SCIENCES, NEW DELHI, INDIA
3- PGIMER, CHANDIGARH, INDIA
4- ZIAUDDIN UNIVERSITY HOSPITAL, KARACHI, PAKISTAN
5- KEM HOSPITAL AND SETH GSMC, MUMBAI, INDIA
6- BANGABANDHU SHEIKH MUJIB MEDICAL UNIVERSITY, DHAKA,BANGLADESH
7- SIR SALIMULLAH MEDICAL COLLEGE, MITFORD HOSPITAL, BANGLADESH
8- CHRISTIAN MEDICAL COLLEGE, VELLORE, INDIA
9- NORK CLINICAL HOSPITAL OF INFECTIOUS DISEASE, ARMENIA
10- ASIAN INSTITUTE OF GASTROENTEROLOGY, HYDERABAD, INDIA
11- IMS &SUM HOSPITAL, ODISA, INDIA
12- GLOBAL HOSPITAL, MUMBAI, INDIA
13- ST JOHN MEDICAL COLLEGE, BANGALORE, INDIA
14- DEPARTMENT OF HEPATOLOGY, HOSPITAL SELAYANG, BATA CAVES, SELANGOR, MALAYSIA
15- CARDINAL SANTOS MEDICAL CENTER, WEST SAN JUAN CITY, METRO MANILA, PHILIPPINES
 
Background/Aims:

 Acute-on-chronic liver failure (ACLF) is a distinct entity, associated with high morbidity and mortality. Hepatitis E (HEV) is one of the leading causes of ACLF in Asia. Inclusion of smaller number of HEV related ACLF patients, differences in criteria to define ACLF and absence of validation studies questions the application of existing prognostic models for HEV related ACLF.  The AARC-ACLF score has been developed using largest data base of 26 Asian countries and found superior to the existing prediction models. It can reliably predict the need for interventions, such as liver transplant, within the first week. However, AARC score has not been validated for HEV related ACLF. Hence, we aim to validate and compare the AARC score in predicting 30, 90 days mortality among patients with ACLF due to hepatitis E. 

Materials and Methods:

 APASL-ACLF research consortium (AARC), consisting of 26 tertiary centers across Asia-Pacific regions, maintains an online database for patients diagnosed to have ACLF according to APASL criteria. All patients who had ACLF with acute hepatitis E were reviewed for the current study. The AARC score was validated and compared it with existing prognostic models AUROC.

Results:

 Out of 2897 patients with ACLF 230 (7.9%) had acute deterioration due to HEV. Mean age was 48.29±13.50 years and 83.9% were male. The most common cause of chronic liver disease was alcohol (26.5%) followed by cryptogenic cirrhosis (25.7%) and NASH (25.7%). Overall 62.2% survived & liver transplantation was done in 4.3% cases. Higher proportion of HE, AKI, organ failure, higher level of creatinine, bilirubin, INR, CTP, MELD, MELD-Na, SOFA, CILF-SOFA, AARC scores were observed among non-survivors as compared to survivors (Table 1). While validating AARC score to predict mortality in HEV related ACLF, The Hosmer–Lemeshow test showed good degree of fit. When we compared AARC score with various prognostic models, AARC score, MELD were found equivalent (AUROC 0.72) but superior to CTP, SOFA, CLIF SOFA, and APACHEE II predicting 30 days mortality (Figure 1). Similar trend was observed while predicting 90 days mortality. 

Table 1: Comparison of survivors and non-survivors with ACLF due to HEV 

 

 

Survivors(n=143)

Non-Survivors(n=87)

p value

Age (Years)

48.5 ± 13.2

47.8 ± 14.0

0.69

Gender: Male

             Female

118(82.5)

25(17.5)

75(86.2)

12(13.8)

0.46

Ascites: Yes

              No

115(81.6)

26(18.4)

69(81.2)

16(18.8)

0.94

HEathy: Yes                            

               No

44(31.2)

97(68.8)

50(59.5)

34(40.5)

<0.001

Sepsis: Yes

            No

19(15.4)

104(84.6)

16(23.2)

53(76.8)

0.18

Variceal bleeding: Yes

                               No

18(66.7)

9(33.3)

13(72.2)

5(27.8)

0.69

AKI: Yes

      No

18(12.9)

122(87.1)

23(27.1)

62(72.9)

0.007

Organ Failure: 0

                       1-2

                       3-5

12(8.4)

116(81.1)

15(10.5)

5(5.7)

60(69)

22(25.3)

0.01

HR /minutes

86.1 ± 13.5

88.3 ± 16.3

0.29

MAP

84.5 ± 10.0

84.3 ± 13.5

0.93

RR/minutes

20.7 ± 2.9

20.4 ± 3.5

0.46

Hb (gm/dl)

11.2 ± 2.1

10.9 ± 2.3

0.30

WBC

11.8 ± 6.5

13.7 ± 11.0

0.13

Platelets

174.0 ± 81.5

162.5 ± 120.4

 

Na (meq/dl)

131.3 ± 6.1

130.2 ± 7.7

0.29

K (meq/dl)

4.0 ± 0.85

3.9 ± 0.92

0.79

Cr (mg/dl) {median, IQR)

0.90[0.61-1.34]

1.2[0.7-2.2]

0.005

Total bilirubin (mg/dl)

21.7 ± 9.7

26.4 ± 9.6

<0.001

Albumin

2.3 ± 0.68

2.36 ± 0.57

0.82

ALT (IU/ml) {median, IQR)

83[55-174]

99[58.2-256.7]

0.18

Alkaline phosphate (IU/ml) {median, IQR)

161.3 ± 134.8

135.8 ± 113.2

0.03

GGT (IU/ml) {median, IQR)

57[39.5-92]

51[32.5-68.2]

0.053

INR

2.1 ±1.1

2.6 ± 1.5

<0.001

PH

7.1 ± 0.32

7.15 ± 0.36

0.55

PCO2

32.3 ± 7.9

31.5 ± 8.4

0.56

CTP

11.3 ± 1.4

12.0 ± 1.4

0.001

MELD

26.5 ± 6.6

31.0 ± 6.1

<0.001

MELD-Na

29.4 ±5.7

33.2 ± 5.0

<0.001

SOFA

8.1 ± 2.5

10.1 ± 3.1

0.003

APACHEE II

14.5 ±5.6

18.4 ± 7.1

0.01

CLIF-SOFA

11.0 ± 2.6

12.2 ± 2.5

0.02

GAHSBL

9.3 ± 1.3

9.8 ± 1.3

0.10

AARC score

9.0 ± 1.8

10.8 ± 2.0

<0.001

 

 

 

Conclusion:

 The AARC score has been found equivalent to MELD score but superior to MELD-NA, CTP, SOFA, CLIF-SOFA and APACHEE predicting 30 and 90 days mortality in patients with HEV related ACLF in Asia pacific region. However, considering AUC 0.72 still there is a room to develop a prognostic model with higher accuracy for HEV-ACLF patients. 

Keywords:

 ACLF, Mortality, AARC score