BACKGROUND & AIMS A better identification of factors predicting death is needed in alcoholic hepatitis (AH). Acute-on-chronic liver failure (ACLF) occurs during the course of liver disease and can be identified when AH is diagnosed (prevalent ACLF [pACLF]) or during follow-up (incidental ACLF [iACLF]). This study analyzed the impact of ACLF on outcomes in AH and the role of infection on the onset of ACLF and death. METHODS Patients admitted from July 2006 to July 2015 suffering from biopsy-proven severe (s)AH with a Maddrey discriminant function (mDF) ≥32 were included. Infectious episodes, ACLF, and mortality were assessed during a 168-day follow-up period. Results were validated on an independent cohort. RESULTS One hundred sixty-five patients were included. Mean mDF was 66.3 ± 20.7 and mean model for end-stage liver disease score was 26.8 ± 7.4. The 28-day cumulative incidence of death (CID) was 31% (95% CI 24-39%). Seventy-nine patients (47.9%) had pACLF. The 28-day CID without pACLF and with pACLF-1, pACLF-2, and pACLF-3 were 10.4% (95% CI 5.1-18.0), 30.8% (95% CI 14.3-49.0), 58.3% (95% CI 35.6-75.5), and 72.4% (95% CI 51.3-85.5), respectively, p <0.0001. Twenty-nine patients (17.5%) developed iACLF. The 28-day relative risk of death in patients developing iACLF was 41.87 (95% CI 5.2-335.1; p <0.001). A previous infection was the only independent risk factor for developing iACLF during the follow-up. Prevalence, incidence, and impact on prognosis of ACLF were confirmed in a validation cohort of 97 patients with probable sAH. CONCLUSIONS ACLF is frequent during the course of sAH and is associated with high mortality. Infection strongly predicts the development of ACLF in this setting. LAY SUMMARY In patients with chronic liver disease, an acute deterioration of liver function combined with single or multiple organ failures is known as acute-on-chronic liver failure. This study shows that acute-on-chronic liver failure is frequent during the course of severe alcoholic hepatitis. In severe alcoholic hepatitis, acute-on-chronic liver failure is associated with high mortality and frequently occurs after an infection.

中文翻译：

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重度酒精性肝炎病程中急性慢性肝衰竭的预后价值

背景和目的 需要更好地识别酒精性肝炎 (AH) 中预测死亡的因素。急性慢性肝功能衰竭 (ACLF) 发生在肝病病程中，可在诊断出 AH（流行性 ACLF [pACLF]）或随访期间（偶发性 ACLF [iACLF]）发现。本研究分析了 ACLF 对 AH 结局的影响以及感染对 ACLF 发作和死亡的影响。方法 纳入 2006 年 7 月至 2015 年 7 月入院的经活检证实的重度 (s)AH 且 Maddrey 判别函数 (mDF) ≥ 32 的患者。在 168 天的随访期内评估了感染事件、ACLF 和死亡率。结果在一个独立的队列中得到验证。结果 包括 165 名患者。平均 mDF 为 66.3 ± 20.7，终末期肝病模型平均评分为 26。8±7.4。28 天累积死亡发生率 (CID) 为 31%（95% CI 24-39%）。79 名患者 (47.9%) 患有 pACLF。无 pACLF 和有 pACLF-1、pACLF-2 和 pACLF-3 的 28 天 CID 分别为 10.4% (95% CI 5.1-18.0)、30.8% (95% CI 14.3-49.0)、58.3% (95% CI) 35.6-75.5) 和 72.4% (95% CI 51.3-85.5)，p <0.0001。29 名患者（17.5%）发生了 iACLF。发生 iACLF 的患者的 28 天死亡相对风险为 41.87（95% CI 5.2-335.1；p <0.001）。既往感染是随访期间发生 iACLF 的唯一独立危险因素。ACLF 的患病率、发生率和对预后的影响在 97 名疑似 sAH 患者的验证队列中得到证实。结论 ACLF 在 sAH 过程中很常见，并且与高死亡率相关。在这种情况下，感染强烈预测 ACLF 的发展。常规总结 在慢性肝病患者中，肝功能急性恶化合并单个或多个器官衰竭被称为急性加慢性肝衰竭。这项研究表明，在严重酒精性肝炎的过程中，急性-慢性肝功能衰竭是常见的。在严重的酒精性肝炎中，急性-慢性肝功能衰竭与高死亡率相关，并且经常发生在感染后。