Risk Factors And Short-Term Outcomes Of Hepatic Encephalopathy In Hepatitis B Virus Associated Acute-on-Chronic Liver Failure

Background and objective: ACLF is an acute and severe disease with high clinical mortality.Its pathogenesis,pathological process,clinical manifestations and prognosis are significantly different from that of cirrhosis.At present,the definition and diagnosis of ACLF are still lack of international unified standards due to different etiology and inducement.It has been reported that about 40% of ACLF patients have HE,which has been proven to be associated with higher mortality.In Asia,hepatitis B cirrhosis is a common disease basis of ACLF.At present,there are few clinical studies on the risk factors and short-term prognosis assessment of HE in ACLF patients caused by HBV infection.The purpose of this study was to analyze and discuss the risk factors and short-term prognosis of patients with HBV-ACLF and the value of different prognostic scoring models in evaluating the short-term prognosis of patients with HBV-ACLF complicated with HE,in order to provide basis for early clinical identification of patients with HBV-ACLF high risk of HE and timely intervention,so as to prevent disease progression and improve prognosis to the greatest extent.Methods: A total of 191 patients diagnosed with ACLF and hospitalized in the First Clinical Hospital Infection Department of Lanzhou University from January2018 to July 2021 were enrolled according to the inclusion and exclusion criteria,including 82 cases with HE and 109 cases without HE.The basic clinical data and laboratory tests of the two groups were compared.To analyze the risk factors of HE in HBV-ACLF patients.Meanwhile,82 HBV-ACLF patients with HE were followed up for 90 days.According to the follow-up results 90 days after discharge,they were divided into death group（n=34 cases）and survival group（n=48 cases）.The AUROC and 95%CI of different prognostic models were analyzed in evaluating the short-term prognosis of patients with HBV-ACLF complicated with HE at 90 days,and the predictive efficacy of different scoring models and their application value in clinical practice were evaluated according to the calculation results.Results: The disease basis of 191 HBV-ACLF patients was hepatitis B cirrhosis,among which 82 cases developed HE.The most common cause of HE in HBV-ACLF patients was various pathogenic microbial infection.The 45.12% of HE patients were infected,and the most common type of infection was spontaneous peritonitis.Compared with the Non-HE group,patients in the HE group had a higher incidence of complications such as gastrointestinal bleeding,abdominal effusion and hyponatremia.Multivariate analysis suggested that gender（OR= 5.794,P=0.048<0.05）,diabetes mellitus（OR= 12.145,P=0.009<0.05）and MELD score（OR=1.347,P<0.001）were independent risk factors for HE.Among 82 HBV-ACLF patients complicated with HE,34 died and 48 survived during 90 days of follow-up after discharge,and the90 d mortality was 41.46%.Multivariate binary logistic regression showed that MELD（OR=1.259,95%CI=1.050-1.509）and serum TC level（OR=0.166,95%CI=0.039-0.694）were independent risk factors for 90 d short-term death in HBV-ACLF patients with HE.Meanwhile,MELD,i MELD,MELD-NA and MELD combined with TC were more accurate in predicting the 90 d survival rate of HBV-ACLF patients complicated with HE（AUROC of the four indicators were 0.811,0.759,0.732 and0.901,both>0.7）.CTP and CLIF-C ADs scoring model had low accuracy in evaluating the 90 days survival rate of HBV-ACLF patients complicated with HE（AUROC of the two indicators were 0.646 and 0.579,both<0.7）.MELD combined with TC scoring model showed high accuracy in judging the 90 d survival rate of HBV-ACLF patients complicated with HE,with the Yolden index of 0.695 and the critical value of18.981.That means when MELD combined with TC score ≥18.981 in patients with HBV-ACLF complicated with HE,the 90 d survival rate was low,while when MELD combined with TC score <18.981,the 90 d survival rate was high,and the critical sensitivity was 88.2% and specificity was 81.3%.Conclusions: 1.Patients with HBV-ACLF complicated with HE are sicker and have more complications.For timely diagnosis and treatment of HBV-ACLF complicated with HE,more attention should be paid to male patients with diabetes and high MELD;2.MELD,i MELD,MELD-NA and MELD combined with TC had high predictive value for 90 days short-term prognosis of patients with HBV-ACLF complicated with HE;MELD combined with TC can be better used in clinical evaluation of short-term prognosis of patients with HBV-ACLF complicated with HE,with more accurate prediction effect and higher clinical application value.