Analysis Of The Efficacy Of Different Guidelines In Artificial Liver Therapy For Acute-on-chronic Liver Failure

Objectives:At present,there is no unified definition and diagnostic criteria for acute-on-chronic liver failure(ACLF),and the efficacy of non-biological artificial liver(NBAL)as a bridging treatment before liver transplantation is also controversial.This study focuses on the differences of short-term efficacy,28-day and 90-day case fatality rate in patients with ACLF after artificial liver treatment using different diagnostic criteria,as well as the prediction of short-term mortality risk,to provide reference for the diagnosis and treatment of ACLF for clinicians.Methods:A total of 126 ACLF patients in the Second Affiliated Hospital of Kunming Medical University from January 2018 to January 2022 were retrospectively collected,which met at least one of the diagnostic criteria for ACLF in the Chinese Medical Association(CMA)or Diagnosis and Treatment of liver failure(2018),the Consensus of the Asian Pacific Association for the Study of the Liver(APASL 2019),and the European Association for the Study of the Liver(EASL 2013),and they were treated with medical routine combined with non-biological artificial liver therapy,and the relevant imaging and laboratory findings were complete.Laboratory indicators included platelet(PLT),prothrombin time(PT),prothrombin activity(PTA),international normalized ratio(INR),albumin(ALB),alanine aminotransferase(ALT),aspartate aminotransferase(AST),total bilirubin(TBIL),direct bilirubin(DBIL),indirect bilirubin(IBIL),cholinesterase(CHE),creatinine(CREA),sodium ion(Na~+),chloride ion(Cl~-),and potassium ion(K~+).Patients were divided into the CMA guideline group,APASL guideline group,and EASL guideline group according to different diagnostic criteria.Chi-squared test and the receiver operating characteristic(ROC)curve for related variables were used to compare the short-term efficacy,28-day and 90-day case fatality rate after artificial liver treatment,and the predictive value of the risk of death in patients with ACLF among the three groups.Results:1 General data comparisonA total of 126 patients receiving artificial liver therapy with ACLF were included in this study.If the patients met multiple guidelines at the same time,they were enrolled for multiple times for analysis,including 110 cases in the CMA guideline group,105cases in the APASL guideline group and 38 cases in the EASL guideline group.The length of hospital stay in the EASL guideline group was significantly less than that in the CMA guideline group and the APASL guideline group,and the difference was statistically significant(P<0.05),and there were no significant differences in gender,age,and etiology among the three groups(P>0.05).2 Comparison of laboratory indexes before and after treatment(1)Intragroup comparison:There was no significant difference in Na~+,Cl~-,PT and INR between the CMA guideline group and the APASL guideline group before and after treatment(P>0.05),ALB and K~+increased significantly after treatment(P<0.05),ALT,AST,TBIL,DBIL,IBIL,CHE,CREA and PLT were lower than before treatment(P<0.05).ALT,AST,DBIL and PLT decreased significantly after treatment in the EASL guideline group(P<0.05),there were no significant differences in ALB,TBIL,IBIL,CREA,CHE,Na~+,K~+,Cl~-,PT and INR(P>0.05).(2)Intergroup comparison:There were significant differences in PT and INR in the CMA guideline group,APASL guideline group and EASL guideline group before treatment(P<0.05),and there were no significant differences in PLT,ALB,ALT,AST,TBIL,DBIL,IBIL,CHE,CREA,Na~+,K~+and Cl~-(P>0.05).After treatment,there were significant differences in TBIL,DBIL,IBIL,PT and INR among the three groups(P<0.05),and there were no significant differences in ALB,ALT,AST,CHE,CREA,Na~+,K~+,Cl~-and PLT(P>0.05).3 Short-term efficacy comparison(1)Overall effective rates comparison:The effective rates of artificial liver therapy in the CMA guideline group,APASL guideline group,and EASL guideline group were55.5%,50.5%and 39.5%,respectively,and there was no significant difference in efficacy among the three groups(χ~2=2.568,P=0.277).(2)The effective rates of the CMA guideline group,APASL guideline group,and EASL guideline group were compared according to the artificial liver treatment modes:The effective rates of plasma exchange(PE)treatment were 51.6%,44.1%and 27.8%(χ~2=2.647,P=0.266).With dual plasma molecular adsorption system(DPMAS),the effective rates were 50.9%,47.9%and 46.7%(χ~2=0.134,P=0.935).The effective rates of PE combined with DPMAS were 68.2%,65.2%and 60.0%(χ~2=0.133,P=0.936).There was no significant difference in the above results.4 Short-term case fatality rate comparison(1)28-day case fatality rate:The 28-day case fatality rates after artificial liver therapy in the CMA guideline group,APASL guideline group,and EASL guideline group were 40.0%,43.6%and 72.2%,respectively,and there was a significant difference in case fatality rates among the three groups(χ~2=11.586,P=0.003).Comparison between groups were found that the difference between the CMA guideline group and the APASL guideline group was not statistically significant(χ~2=0.261,P=0.610),there was a significant difference between the CMA guideline group and EASL guideline group(χ~2=11.003,P=0.001),and also a significant difference between the APASL guideline group and EASL guideline group(χ~2=8.528,P=0.003).(2)90-day case fatality rate:The 90-day case fatality rates after artificial liver therapy in the CMA guideline group,APASL guideline group,and EASL guideline group were 50.0%,51.1%and 77.8%,respectively,and there was a significant difference in case fatality rates among the three groups(χ~2=9.133,P=0.010).Comparison between groups were found that the difference between the CMA guideline group and the APASL guideline group was not statistically significant(χ~2=0.022,P=0.882),there was a significant difference between the CMA guideline group and EASL guideline group(χ~2=8.351,P=0.004),and also a significant difference between the APASL guideline group and EASL guideline group(χ~2=7.650,P=0.006).(3)Short-term(within 90 days)death risk prediction:Compared with the CMA guideline and APASL guideline,EASL guideline had a better value.The sensitivity and specificity of EASL guideline for predicting short-term mortality risk were 22.2%and92.3%respectively,and the area under the ROC curve(AUC)was 0.576.Conclusions:1.The liver,kidney,and coagulation function of the CMA guideline group and APASL guideline group improved better after artificial liver treatment.2.The short-term efficacy of artificial liver(PE,DPMAS,PE combined with DPMAS sequential)in the CMA guideline group,APASL guideline group and EASL guideline group was the same,but the effective rate of PE combined with DPMAS was higher than that of PE or DPMAS alone.3.The 28-day and 90-day case fatality rates of the EASL guideline group was higher.4.The EASL-ACLF diagnostic criteria help identify patients at higher risk of short-term death.