The PREDICT study uncovers three clinical courses of acutely decompensated cirrhosis that have distinct pathophysiology

The PREDICT study uncovers three clinical courses of acutely decompensated cirrhosis that have distinct pathophysiology Graphical abstract Infections ACLF Death Different clinical courses of acutely decompensated cirrhosis Pre-ACLF Unstable decompensated cirrhosis Stable decompensated cirrhosis 0 90 180 270 360 Days Highlights Patients with acutely decompensated cirrhosis without ACLF develop 3 different clinical courses. Patients with pre-ACLF develop ACLF within 90 days and have high systemic inflammation and mortality. Patients with unstable decompensated cirrhosis suffer from complications of severe portal hypertension. Patients with stable decompensated cirrhosis have less frequent complications and lower 1-year mortality risk. Authors Jonel Trebicka, Javier Fernandez, Maria Papp, .,RichardMoreau,PaoloAngeli, Vicente Arroyo Correspondence [email protected] (J. Trebicka). Lay summary Herein, we describe, for the first time, 3 different clinical courses of acute decompensation (AD) of cirrhosis after hospital admission. The first clinical course includes patients who develop acute-on-chronic liver failure (ACLF) and have a high short-term risk of death –termed pre-ACLF. The second clinical course (unstable decompensated cirrhosis) includes patients requiring frequent hospitalizations unrelated to ACLF and is associated with a lower mortality risk than pre-ACLF. Finally, the third clinical course (stable decompensated cirrhosis), includes two-thirds of all patients admitted to hospital with AD –patients in this group rarely require hospital admission and have a much lower 1-year mortality risk. Research Article Cirrhosis and Liver Failure https://doi.org/10.1016/j.jhep.2020.06.013 e57 © 2020 European Association for the Study of the Liver. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). J. Hepatol. 2020, 73, 842–854 The PREDICT study uncovers three clinical courses of acutely decompensated cirrhosis that have distinct pathophysiologyq Jonel Trebicka 1,2, *, Javier Fernandez 1,4 , Maria Papp 5 , Paolo Caraceni 6 , Wim Laleman 13 , Carmine Gambino 7 , Ilaria Giovo 8 , Frank Erhard Uschner 2 , Cesar Jimenez 9 , Rajeshwar Mookerjee 10 , Thierry Gustot 11 , Agustin Albillos 12 , Rafael Bañares 14 , Martin Janicko 15 , Christian Steib 16 , Thomas Reiberger 17 , Juan Acevedo 18 , Pietro Gatti 19 , William Bernal 20 , Stefan Zeuzem 2 , Alexander Zipprich 21 , Salvatore Piano 7 , Thomas Berg 22 , Tony Bruns 23,34 , Flemming Bendtsen 24 , Minneke Coenraad 25 , Manuela Merli 26 , Rudolf Stauber 27 , Heinz Zoller 28 , José Presa Ramos 29 , Cristina Solè 4 , Germán Soriano 30 , Andrea de Gottardi 31 , Henning Gronbaek 32 , Faouzi Saliba 33 , Christian Trautwein 34 , Osman Cavit Özdogan 35 , Sven Francque 36 , Stephen Ryder 37 , Pierre Nahon 38 , Manuel Romero-Gomez 39 , Hans Van Vlierberghe 40 , Claire Francoz 41,42 , Michael Manns 43 , Elisabet Garcia 1 , Manuel Tufoni 6 , Alex Amoros 1 , Marco Pavesi 1 , Cristina Sanchez 1 , Anna Curto 1 , Carla Pitarch 1 , Antonella Putignano 11 , Esau Moreno 1 , Debbie Shawcross 20 , Ferran Aguilar 1 , Joan Clària 1,4 , Paola Ponzo 8 , Christian Jansen 3 , Zsuzsanna Vitalis 5 , Giacomo Zaccherini 6 , Boglarka Balogh 5 , Victor Vargas 9 , Sara Montagnese 7 , Carlo Alessandria 8 , Mauro Bernardi 6 , Pere Ginès 4 , Rajiv Jalan 1,10 , Richard Moreau 1,41,42 , Paolo Angeli 1,7,† , Vicente Arroyo 1,† , for the PREDICT STUDY group of the EASL-CLIF Consortium ‡ 1 European Foundation for Study of Chronic Liver Failure, EF-Clif, Barcelona, Spain; 2 JW Goethe University Hospital, Frankfurt, Germany; 3 University Hospital Bonn, Bonn, Germany; 4 Hospital Clinic, IDIBAPS and CIBEehd, Barcelona, Spain; 5 University of Debrecen, Faculty of Medicine, Institute of Medicine, Department of Gastroenterology, Debrecen, Hungary; 6 University of Bologna, Bologna, Italy; 7 Department of Medicine, University of Padova, Padova, Italy; 8 Division of Gastroenterology and Hepatology, Città della Salute e della Scienza Hospital, University of Torino, Italy; 9 Liver Unit, Hospital Vall d’Hebron, Universitat Autònoma de Barcelona, CIBEREHD, Barcelona, Spain; 10 UCL Medical School, Royal Free Hospital, London, United Kingdom; 11 Universite Libre de Bruxelles, Bruxelles, Belgium; 12 Department of Gastroenterology, Hospital Universitario Ramón y Cajal, IRYCIS, University of Alcalá, CIBEREHD, Madrid, Spain; 13 University of Leuven, Leuven, Belgium; 14 Gastroenterology and Hepatology Department, Hospital General Universitario Gregorio Marañón, Facultad de Medicina, Universidad Complutense, CIBERehd, Madrid, Spain; 15 Pavol Jozef Safarik University in Kosice, Kosice, Slovakia; 16 Department of Medicine II, University Hospital Munich, Munich, Germany; 17 Medical University of Vienna, Vienna, Austria; 18 University Hospitals Plymouth NHS Trust, Plymouth, UK; 19 Internal Medicine PO Ostuni, ASL Brindisi, Italy; 20 King’s College Hospital, London, United Kingdom; 21 University Hospital Halle-Wittenberg, Halle (Saale), Germany; 22 Division of Hepatology, Department of Medicine II, Leipzig University, Medical Center, Leipzig, Germany; 23 Jena University Hospital, Jena, Germany; 24 Hvidovre University Hospital, Hvidovre, Denmark; 25 Leiden University Medical Center, Leiden, Netherlands; 26 Department of Translational and Precision Medicine, Universitá Sapienza Roma, Roma, Italy; 27 Medical University of Graz, Graz, Austria; 28 Medical University of Innsbruck, Innsbruck, Austria; 29 CHTMAD Vila Real, Vila Real, Portugal; 30 Hospital de la Santa Creu i Sant Pau and CIBERehd, Barcelona, Spain; 31 University Clinic of Visceral Surgery and Medicine-Inselspital, Bern and Ente Ospedaliero Cantonale, Universita della Svizzera Italiana, Lugano, Switzerland; 32 Aarhus University Hospital, Aarhus, Denmark; 33 AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Universite Paris Saclay, INSERM Unit 1193, Villejuif, France; 34 Aachen University Hospital, Aachen, Germany; 35 Marmara University, Istanbul, Turkey; 36 University Hospital Antwerp, Antwerpen, Belgium; 37 NIHR Biomedical Research Centre at Nottingham University Hospitals NHS Trust and the University of Nottingham, Nottingham, United Kingdom; 38 AP-HP, Hôpital Jean Verdier, Service d’Hépatologie, Bondy; Université Paris 13, Sorbonne Paris Cité, “Equipe labellisée Ligue Contre le Cancer”, Saint-Denis; Inserm, UMR- 1162, “Génomique fonctionnelle des tumeurs solides”, Paris, France; 39 Virgen del Rocío University Hospital, Sevilla, Spain; 40 Ghent University Keywords: Chronic liver disease; Non-elective admission; Acute complications; Outcome; Risk factors. Received 16 March 2020; received in revised form 5 June 2020; accepted 6 June 2020; available online 13 July 2020 qGuest Editor: Dominique Valla. *Corresponding author. Address: European Foundation for Study of Chronic Liver Failure, EF-Clif, Travesera de Gracia 11, 7th Floor, 08021 Barcelona, Spain. Tel.: +34 93 227 14 11; fax +34 93 227 14 19. E-mail address: [email protected] (J. Trebicka). † Denotes shared last authorship. ‡ EASL-CLIF consortium collaborators listed at the end of the manuscript. https://doi.org/10.1016/j.jhep.2020.06.013 Journal of Hepatology 2020 vol. 73 j842–854 Research Article Cirrhosis and Liver Failure Hospital, Ghent, Belgium; 41 APHP, Hôpital Beaujon, Service d’Hépatologie, Clichy, France; 42 Inserm, Université de Paris, Centre de Recherche sur LInflammation, Paris, France; 43 Hannover Medical School, Hannover, Germany See Editorial, pages 755–756 Background & Aims: Acute decompensation (AD) of cirrhosis is defined as the acute development of ascites, gastrointestinal hemorrhage, hepatic encephalopathy, infection or any combination thereof, requiring hospitalization. The presence of organ failure(s) in patients with AD defines acute-on-chronic liver failure (ACLF). The PREDICT study is a European, prospective, observational study, designed to characterize the clinical course of AD and to identify predictors of ACLF. Methods: A total of 1,071 patients with AD were enrolled. We collected detailed pre-specified information on the 3-month period prior to enrollment, and clinical and laboratory data at enrollment. Patients were then closely followed up for 3 months. Outcomes (liver transplantation and death) at 1 year were also recorded. Results: Three groups of patients were identified. Pre-ACLF patients (n = 218) developed ACLF and had 3-month and 1-year mortality rates of 53.7% and 67.4%, respectively. Unstable decompensated cirrhosis (UDC) patients (n = 233) required > −1 readmission but did not develop ACLF and had mortality rates of 21.0% and 35.6%, respectively. Stable decompensated cirrhosis (SDC) patients (n = 620) were not readmitted, did not develop ACLF and had a 1-year mortality rate of only 9.5%. The 3 groups differed significantly regarding the grade and course of systemic inflammation (high-grade at enrollment with aggravation during follow-up in pre-ACLF; low-grade at enrollment with subsequent steady-course in UDC; and low-grade at enrollment with subsequent improvement in SDC) and the prevalence of surrogates of severe portal hypertension throughout the study (high in UDC vs. low in pre-ACLF and SDC). Conclusions: Acute decompensation without ACLF is a heterogeneous condition with 3 different clinical courses and 2 major pathophysiological mechanisms: systemic inflammation and portal hypertension. Predicting the development of ACLF remains a major future challenge. ClinicalTrials.gov number: NCT03056612. Lay summary: Herein, we describe, for the first time, 3 different clinical courses of acute decompensation (AD) of cirrhosis after hospital admission. The first clinical course includes patients who develop acute-on-chronic liver failure (ACLF) and have a high short-term risk of death –termed pre-ACLF. The second clinical course (unstable decompensated cirrhosis) includes patients requiring frequent hospitalizations unrelated to ACLF and is associated with a lower mortality risk than pre-ACLF. Finally, the third clinical course (stable decompensated cirrhosis), includes two-thirds of all patients admitted to hospital with AD –patients in this group rarely require hospital admission and have a much lower 1-year mortality risk. © 2020 European Association for the Study of the Liver. Published by Elsevier B.V. This is an open access article under the CC BY-NC-ND license (http://creativecommons.org/licenses/by-nc-nd/4.0/). Introduction Acute decompensation (AD) of cirrhosis is defined as the acute development of ascites, hepatic encephalopathy, gastrointestinal hemorrhage or bacterial infections or any combination thereof. 1–3 AD is an extremely relevant feature during the clinical course of cirrhosis. The first episode of AD signals the transition from compensated to decompensated cirrhosis. 4 Decompensated cirrhosis is characterized by recurrent episodes of AD. Finally, recent data from the CANONIC study have shown that AD has 2 distinct clinical presentations, depending on the presence or absence of organ failures and the grade of systemic inflammation. 5–8 The presence of both organ failures and high-grade systemic inflammation is the hallmark of acute-on-chronic liver failure (ACLF), a syndrome associated with a very high 28-day mortality rate, while AD is associated with moderate systemic inflammation and a low 28-day mortality rate. Systemic inflammation in AD and ACLF frequently develops in association with exogenous precipitating events (mainly bacterial infections or acute alcoholic liver injury). However, it might also be secondary to translocation of intestinal bacterial immunogenic material to the systemic circulation. 9,10 Systemic inflammation may induce organ dysfunction/failure via a direct immunopathological effect on peripheral organs or via mitochondrial dysfunction, both of which have been identified in decompensated cirrhosis. 8 The CANONIC study was specifically designed to characterize ACLF but did not provide detailed information on the clinical context prior to and after ACLF and AD development. Yet, the CANONIC study showed that patients with AD had very low mortality rate (2%) at 28 days but a substantial mortality rate (10%) at 90 days, suggesting a heterogeneity of clinical course in patients with AD. Detailed information on this period is an unmet medical need for the rational management of patients with AD and the prevention of ACLF development. To answer these questions, we designed the PREDICT study (PREDICTing Acute-on-Chronic Liver Failure), the second prospective large-scale observational investigation performed by the European Association for the Study of the Liver (EASL)-Chronic Liver Failure (CLIF) Consortium. It included 1,071 patients with cirrhosis hospitalized for the treatment of an episode of AD without ACLF. The current article reports the results of the first study derived from this investigation, the aim of which was to characterize the clinical course and pathophysiology of AD, and to predict the development of ACLF. Patients and methods Study oversight The PREDICT study is a European, multicenter, prospective, observational study performed in 48 hospitals. Each hospital had a liver unit, specific ward(s) for liver patients and intensive care facilities, and all of them had access to a liver transplantation program. The study protocol (available with the full text of this article) was approved by the institutional review board (IRB) at each participating center. Patients were screened and enrolled from March 2017 to July 2018. Written informed consent was obtained from patients or their legal surrogates before enrollment. An investigator was responsible for enrolling patients in the study at each center, ensuring adherence to the protocol, and completing the electronic case-report form. Data were continuously monitored on-line by the Data Management Center of the Journal of Hepatology 2020 vol. 73 j842–854 843 EF-Clif. All authors had access to the study data and reviewed and approved the final manuscript. Patients A total of 1,421 patients non-electively admitted for the treatment of an episode of AD were eligible, of whom 148 patients met exclusion criteria (Table S1), 202 patients presented with ACLF and 1,071 patients were analyzed. Among these, 218 developed AD for the first time, and the remaining 853 had a prior history of AD. The diagnosis of cirrhosis was based on previous liver biopsy findings or a composite of clinical signs and findings provided by laboratory test results, endoscopy and ultrasonography. Diagnostic criteria for AD upon hospitalization were based on the development of ascites, hepatic encephalopathy, gastrointestinal hemorrhage, infection, or any combination of these. Importantly, AD was not due to an isolated bacterial infection in any of the enrolled patients. Diagnosis of ACLF during follow-up was performed according to the CANONIC study criteria. 7 Organ failure and organ dysfunction were defined according to the CLIF consortium (CLIF-C) organ failure (OF) score. 11 Study design Pre-specified clinical data, standard laboratory data and biological samples for biobanking were obtained at enrollment and sequentially during the follow-up visits (Fig. 1). The electronic case-report form was designed to collect granularity in the clinical data and the detailed queries answered remaining issues in case of inconsistencies. Herein, only clinical and standard laboratory data are analyzed. Data obtained at enrollment Two categories of pre-specified information were obtained at enrollment. The first category included general characteristic and demographic data, specific data related to the AD episode at enrollment, results of physical examination and standard laboratory analysis, including differential white-cell blood count (WBC) and C-reactive protein (CRP) levels, as markers of systemic inflammation. Cultures were routinely performed in patients with suspected bacterial infections. The second category of pre-specified data was related to the past medical history and included: a) the timepoint of the onset of decompensated cirrhosis (as defined by the first episode of AD); b) the complications of AD occurring within the last 3 months prior to enrollment; c) treatment of complications (including prior transjugular portosystemic shunt stent [TIPS] and its indication); and d) any hospitalization during the last 3 months prior to enrollment. Data regarding onset of decompensated cirrhosis could be obtained in 612 patients. Data No ACLF (Visit V1) CLIF-C AD <50 CLIF-C AD ≥50 Visit d7-10 (V2) Visit d7-10 (V2) Week 4/8 (A1/A2) Re-admission (AD)ACLF (E1) Visit d7-10 (V2) Week 12 (V3)Week 12 (V3) Outcome in 6 and 12 months Outcome in 6 and 12 months Outcome in 6 and 12 months Past medical history: a) the time point of the onset of decompensation Medical history during the last 3 months: b) complications of AD c) treatment of complications d) any hospitalization 3-month period prior to enrollment 3-month follow-up period Enrollment OBSERVATIONAL PERIOD V: planned visits E: visits in case of ACLF A: additional planned visits AD: readmission visits Fig. 1. Scheme of visits and collection of data and samples during the 6-month observational period. The 6-month period which included the 3-month period prior to enrollment, the enrollment visit, and the 3-month follow-up period after enrollment. At enrollment patients were initially stratified into 2 groups based on the risk of ACLF development: high-risk group (CLIF-C AD-score > −50) and low-risk group (CLIF-C AD-score <50). 12 In the high-risk group, the scheduled visits were performed at enrollment (visit 1) and 1, 4, 8 and 12 weeks after enrollment (visits 2–5). In the low-risk group, scheduled visits were performed only at enrollment (visit 1) and week 1 (visit 2) and 12 (visit 5) after enrollment. Any patient of both groups developing ACLF within the follow-up period received unplanned ACLF visits at the time of diagnosis of ACLF and 7 days later. Additional study visits were performed whenever a patient had tobe readmitted for any reason except ACLF (readmission visits) in the high-risk group only, but the number of readmissions was recorded in both groups. Finally, data on liver transplantation or death and causes of death were prospectively collected 3, 6 and 12 months after enrollment in all patients. ACLF, acute-on-chronic liver failure; CLIF-C AD, Chronic Liver Failure Consortium acute decompensation. 844 Journal of Hepatology 2020 vol. 73 j842–854 Research Article Cirrhosis and Liver Failure regarding the occurrence of ascites, gastrointestinal hemorrhage, hepatic encephalopathy, bacterial infections and hospitalizations within the last 3-month period prior to enrollment were obtained in 860, 796, 793, 791 and 831 patients, respectively. Data obtained during follow-up After enrollment, patients were prospectively followed-up for a period of 3 months. The scheme of visits and collection of data and samples at enrollment and during the 3-month follow-up period after enrollment is indicated in Fig. 1. Finally, data on liver transplantation or death and causes of death were prospectively collected 3, 6 and 12 months after enrollment in all patients. Defining the 6-month observational period Of note, according to the pattern of data collection described earlier, we defined a 6-month observational period, which included the 3-month period prior to enrollment, the enrollment visit and the 3-month follow-up period after enrollment (Fig. 1). Amendment to the initial study protocol During the first 8 months of the study, 720 patients were consecutively enrolled, and used for prevalence calculations. Subsequently, since the number of patients developing ACLF was low, we amended the study protocol to enroll only high-risk patients. After IRB approval of this amendment, the last 351 patients were enrolled in the study. Statistical analysis Patient stratification Patient stratification was performed based on the clinical course duringthe3-monthfollow-upperiodforseveralreasons:i)the main objective of the study was the characterization of the clinical course after enrollment; ii) a preliminary analysis of an incomplete set of consecutive patients included in the PREDICT study showed that AD consisted of a single complication (either ascites, encephalopathy or gastrointestinal hemorrhage) in only 50% of patients. The remaining patients had 2 or 3 simultaneous complications, making stratification based on complications atenrollment extremelycomplex. iii) By contrast, stratification of patients based on ACLF development (yes or no) and clinical course profile (unstable vs. stable, among ACLF- free patients) during the 3-month follow-up was simpler and more appropriate for addressing the main objective of the study. Therefore, our patients were stratified into 3 groups for data analysis: i) pre-ACLF group: patients who developed ACLF within 90 days of enrollment; ii) unstable decompensated cirrhosis (UDC) group: patients who experienced at least 1 hospital readmission, but without ACLF development within the 90-day follow-up period; and iii) stable decompensated cirrhosis (SDC) group: patients without ACLF development or readmissions within the 90-day follow-up period. Because bacterial infections are major precipitants of AD and ACLF, and systemic inflammation is the hallmark of AD and ACLF, infections and systemic inflammation were considered in detail when characterizing these groups. Data analysis Discrete variables are summarized as counts (percentages) and continuous variables as mean ± SD. Non-normally distributed variables are summarized as median (IQR) and were logtransformed for some statistical analyses and for graphical comparisons. In univariate statistical comparisons, the chisquare test was used for categorical variables, whereas the Student’sttest or analysis of variance were used for normally distributed continuous variables and the Wilcoxon signed-rank test or the Kruskal-Wallis test were used for non-normally distributed continuous variables. In all statistical analyses, significance was set at p<0.05. Tools to predict ACLF development For the prediction of ACLF development during the 90-day follow-up period, the CLIF-C ACLF development score (CLIF-C ACLF-D score) was fitted according to the TRIPOD recommendations (see TRIPOD checklist). There were no missing data in most potential predictors of ACLF development at enrollment, except for serum albumin and plasma CRP levels, whose values were not available, respectively, in 5%, 9% and 8% of patients from the pre-ACLF, UDC, and SDC groups and in 20%, 13% and 11% of patients from the 3 groups (Table S2). Therefore, for multivariate analysis, we assumed that these missing values could be considered at random and carried out a multiple imputation based on a mixed model including all potential predictors significantly associated with ACLF in the univariate analysis. 13 We used the proportional-hazards model for competing risks proposed by Fine and Gray to identify the best subset of independent predictors associated with the onset of ACLF and to develop a new predictive score (the CLIF-C ACLF-D score). 14 Liver transplantation and death could be considered as ‘competing’ events in the competing risks model. The initial model included the most relevant characteristics at enrollment found to be significantly associated (both clinically and statistically) with ACLF development at 3 months in the univariate analysis (Table S3). In the final CLIF-C ACLF-D score model, the best subset of independent predictors was selected based on a stepwise forward procedure with p-in <0.05 and p-out <0.10 for the change in model log-likelihood (Table S4). The coefficients estimated for each predictor were used as relative weights to compute the score. Because the PREDICT study is the only thorough investigation on the factors leading to ACLF, no other cohort could be used for external validation. As a result, we had to carry out a random split-sample derivation and validation processes for the new score. The subset of patients used to derive the score included two-thirds of patients (n = 707) randomly selected from each patient group. The internal score validation was performed on the remaining third of patients (n = 364) and compared the predictive ability of the CLIF-C ACLF-D score with those of the CLIF-C AD score, MELD, MELD-sodium and Child-Pugh scores by estimating the corresponding Harrel’C-indexes and 95% CIs both in the derivation and validation sets. As a complementary tool to predict ACLF development, a decision tree model was fitted using the 980 patients with information about the development of ACLF. Patients, who died or weretransplanted without presenting ACLF before 3 months were excluded. The clinical variables selected for the model were the independent predictors of ACLF development obtained in the multivariate analysis for the CLIF-C ACLF-D score. The decision tree algorithm selected the most relevant of these clinical variables, their position within the decision tree and their optimal cut-off values. The model was fitted using R software (version 3.6.3) rpart package with settings minsplit = 10 and maxdepth = 5. Also, the complexity parameter was set by default to 0.01. Model parameters were estimated using the function tune.rpart from the Journal of Hepatology 2020 vol. 73 j842–854 845 Table 1. Patient characteristics prior to, at, and after enrollment. Characteristic Pre-ACLF (n = 218) UDC (n = 233) SDC (n = 620) pvalue Age, years, mean ± SD 61.1 ± 10.0 60.9 ± 10.6 57.9 ± 11.0 a <0.001 Female sex, n (%) 70 (32.1) 74 (31.8) 200 (32.3) 0.990 Etiology of cirrhosis, n (%) Alcohol 107 (49.1) 143 (61.4) b 346 (55.9) 0.032 HCV 14 (6.4) 12 (5.2) 41 (6.6) 0.727 Alcohol and HCV 10 (4.6) 8 (3.4) 33 (5.3) 0.506 Non-alcoholic steatohepatitis 16 (7.3) 17 (7.3) 48 (7.8) 0.965 Other etiologies 70 (32.1) 51 (21.9) b 150 (24.2) b 0.028 Events prior to enrollment, n (%) Ascites 130 (66.7) 122 (65.9) 229 (47.7) a <0.001 Hepatic encephalopathy 46 (25.4) 54 (31.4) 75 (17.1) a <0.001 Gastrointestinal hemorrhage 17 (9.6) 29 (17.1) b 62 (13.9) 0.125 Any hospitalization 106 (56.7) 119 (65.0) 210 (45.6) a <0.001 Data at enrollment Clinical data, organ failures and organ dysfunctions, n (%) Ascites 173 (79.4) 170 (73.0) 415 (66.9) b 0.002 Hepatic encephalopathy 65 (29.8) 73 (31.3) 168 (27.1) 0.428 Gastrointestinal hemorrhage 16 (7.3) 39 (16.7) b 97 (15.6) b 0.005 No organ failure or dysfunction 50 (22.9) 80 (36.5) b 291 (46.9) a <0.001 Liver failure 29 (13.3) 11 (4.7) b 30 (4.8) b <0.001 Liver dysfunction 51 (23.4) 36 (15.5) b 84 (13.5) b 0.003 Circulatory dysfunction 20 (9.2) 43 (18.5) b 50 (8.1) c <0.001 Renal dysfunction 51 (23.4) 17 (7.3) b 40 (6.5) b <0.001 Coagulation failure 8 (3.7) 4 (1.7) 7 (1.1) b 0.050 Coagulation dysfunction 29 (13.3) 19 (8.2) 46 (7.4) b 0.029 Brain failure 4 (1.8) 4 (1.7) 16 (2.6) 0.676 Brain dysfunction 59 (27.1) 67 (28.8) 144 (23.2) 0.197 Respiratory dysfunction 10 (4.6) 8 (3.4) 29 (4.7) 0.722 Main reason for hospitalization Ascites 105 (48.4) 106 (45.5) 267 (43.1) 0.382 Hepatic encephalopathy 29 (13.4) 34 (14.6) 82 (13.2) 0.870 Gastrointestinal hemorrhage 13 (6.0) 37 (15.9) b 110 (17.7) b <0.001 Bacterial infection 32 (14.7) 27 (11.6) 84 (13.5) 0.603 Other 38 (17.5) 29 (12.4) 77 (12.4) 0.147 Biomarkers of systemic inflammation, median (IQR) White-cell count, ×10 9 /L 7.2 (4.9–9.8) 6.1 (4.3–8.5) b 6.0 (4.2–8.7) b 0.002 Serum C-reactive protein, mg/L 23 (11–41) 16 (8–35) b 15 (6–36) b <0.001 Measurements estimating organ function Serum bilirubin, mg/dl, median (IQR) 3.9 (1.9–9.0) 2.6 (1.3–5.4) b 2.3 (1.4–4.5) b <0.001 Serum albumin, g/dl, mean ± SD 2.7 ± 0.7 2.8 ± 0.6 3.0 ± 0.6 a <0.001 INR, median (IQR) 1.6 (1.4–1.9) 1.4 (1.3–1.7) b 1.4 (1.2–1.7) b <0.001 Serum creatinine, mg/dl, median (IQR) 1.1 (0.8–1.5) 0.9 (0.7–1.2) b 0.8 (0.7–1.1) a <0.001 Plasma sodium, mEq/L, mean ± SD 134 ± 6 135 ± 5 136 ± 5 a <0.001 Severity scores, mean ± SD Child-Pugh 9.8 ± 1.8 9.2 ± 1.7 b 8.7 ± 1.8 a <0.001 MELD 19 ± 5 16 ± 5 b 15 ± 5 a <0.001 MELD-sodium 23 ± 5 19 ± 5 b 18 ± 5 a <0.001 CLIF-C AD 57 ± 8 53 ± 8 b 50 ± 8 a <0.001 Data after enrollment Mortality rates, n (%) 90-day mortality rate 117 (53.7) 49 (21.0) – 1-year mortality rate 147 (67.4) 83 (35.6) 59 (9.5) Main causes of death, n (%) ACLF 130 (88.4) 25 (30.1) b 29 (49.2) a <0.001 Hypovolemic shock 4 (2.7) 14 (16.9) b 3 (5.1) c <0.001 Other causes of death 6 (4.1) 15 (18.1) b 15 (25.4) b <0.001 Unknown 7 (4.8) 29 (34.9) b 12 (20.3) b <0.001 Liver transplantation within 12 months after enrollment 33 (15.1) 39 (16.7) 73 (11.8) 0.125 (continued on next page) 846 Journal of Hepatology 2020 vol. 73 j842–854 Research Article Cirrhosis and Liver Failure R package e1071, to select the best decision tree model, according to accuracy, sensitivity and specificity. A decision tree plot was generated based on the model fitted. A 10-Fold cross validation was used to reduce over-fitting and to assess the discriminative ability of the model, by estimating the corresponding sensitivity and specificity of the model and computing the area under the receiver-operating-characteristic curve (AUC). Results Heterogeneity of the clinical course of AD Clinical course of patients with AD As expected, the pre-ACLF group, which included 218 patients who developed ACLF during the 3-month follow-up period after enrollment, had the highest 3-month and 1-year mortality rates (53.7% and 67.4%, respectively) (Table 1). Twenty-two patients with pre-ACLF were transplanted after ACLF developed within the 3-month follow-up period. The 233 patients included in the UDC group, who did not develop ACLF, but who died or required at least 1 hospital readmission within the 3-month follow-up period, had 3-month and 1-year mortality rates of 21.0% and 35.6%, respectively; 177 of these patients required 1 readmission, 32 patients 2 readmissions, and 17 patients > −3 readmissions. Fourteen patients with UDC were transplanted after readmission for an AD episode within the 3-month follow-up period. Finally, the 620 patients included in the SDC group, who did not develop ACLF, require hospital readmission, nor die during the 3-month follow-up period after enrollment, showed very low mortality (9.5%) within the 1-year follow-up period after enrollment. Among the 720 patients consecutively enrolled during the first 8 months after the onset of the study, 425 (59%) were in SDC group. Twenty-eight patients with SDC were transplanted from the waitlist without ACLF or a new episode of AD within the 3-month follow-up period. The clinical course of patients with pre-ACLF was characterized by a huge density of bacterial infections, episodes of ACLF and death, which are summarized as events (Fig. 2). A total of 120 patients (55% of this group) developed ACLF during the first hospitalization and 98 developed the syndrome from first discharge to the end of the 3-month follow-up period. The bacterial infection density curve chronologically preceded the ACLF density curve, and both curves preceded the mortality density curve, supporting a cause to effect relationship between the 3 events. The extreme proximity between the bacterial infection and ACLF density curves reflects that ACLF is a hyperacute process with a very short time period between precipitating events and the onset of the syndrome. Fig. 3A shows the cumulative rate of weekly occurrence of ACLF during the first 90 days after enrollment of patients with pre-ACLF. Fig. 3B shows that using the 90 th day after enrollment as a landmark, the cumulative incidence of death 1 year after enrollment was also higher among patients assigned to the pre-ACLF group than among those assigned to 1 of the other 2 groups. The density of events in the UDC group was remarkably lower than the density of events in the pre-ACLF group. Although this feature was mainly due to the lack of ACLF episodes in the UDC group, the density of bacterial infections and deaths were also lower. Finally, although the density of bacterial infections at first presentation in the SDC group was as high as in the UDC group, it was remarkably lower during the rest of the 3-month follow-up period. There were no significant differences between the 3 groups of patients regarding the etiology of cirrhosis (Table 1), prevalence of active alcoholism (26.6%, 23.2% and 27.6%, respectively) or presence of hepatocellular carcinoma (within Milan criteria) at enrollment (5.4%, 6.5% and 3%, respectively). Moreover, there was Table 1. (continued) Characteristic Pre-ACLF (n = 218) UDC (n = 233) SDC (n = 620) pvalue Data after enrollment Indicators of severe portal hypertension, n (%) TIPS d 18 (8.3) 33 (14.2) b 63 (10.2) 0.107 TIPS for gastrointestinal hemorrhage 4 (1.8) 12 (5.4) 26 (4.2) 0.145 Any episode of gastrointestinal hemorrhage d 48 (22.0) 76 (32.6) b 155 (25.0) c 0.016 pvalues were obtained using chi-square test. ACLF, acute-on-chronic liver failure; CLIF-C AD, Chronic Liver Failure Consortium acute decompensation; INR, international normalized ratio; MELD, model for end-stage liver disease; SDC, stable decompensated cirrhosis; TIPS, transjugular intrahepatic portosystemic shunt; UDC, unstable decompensated cirrhosis. a Significantly different from the pre-ACLF group and UDC groups. b Significantly different from the pre-ACLF group. c Significantly different from the UDC group. d At any time of the 6-month observational period, this being defined by the 3 months prior to, and the 3 months as of enrollment. Pre-ACLF group (n = 218) UDC group (n = 233) SDC group (n = 620) 0306090 Infections ACLF Death Days Fig. 2. Density curves of events during the 3-month follow-up period after enrollment in patients with pre-ACLF, UDC and SDC. The zero timepoint corresponds to enrollment into the study. Bacterial infections are represented in red, ACLF in green, and deaths in blue. ACLF, acute-on-chronic liver failure; SDC, stable decompensated cirrhosis; UDC, unstable decompensated cirrhosis. Journal of Hepatology 2020 vol. 73 j842–854 847 no between-group difference in the number of patients with alcohol cessation (52 [23.9%] patients for pre-ACLF, 46 [19.7%] for UDC, and 146 [23.6%] for SDC; p= 0.456) and the number of those receiving HCV therapy (4 [1.9%] patients for pre-ACLF, 3 [1.3%] for UDC, and 14 [2.3%] for SDC; p= 0.650). Duration of the decompensated phase of cirrhosis The time-course density curves of liver transplantation or death in the 234 patients developing these events are shown in Fig. 4A. Time zero in this figure represents the onset of decompensated cirrhosis. Therefore, this analysis estimates the between-group differences in the length of the entire phase of decompensated cirrhosis. The pre-ACLF density curve preceded the UDC density curve, and both curves preceded the SDC density curve. These findings clearly indicate that ACLF development in patients with pre-ACLF significantly reduced the duration of the decompensated phase of the disease. Confirming these observations, the median time from the onset of decompensated cirrhosis to death or liver transplantation was 12 months (IQR 5.2–25.8) in patients with pre-ACLF, 14 months (9.6–24.3) in patients with UDC (p= 0.01 vs. patients with pre-ACLF), and 20 months (11.4–41.3) in patients with SDC (p= 0.04 vs. patients with UDC). These findings are confirmed by comparing individual values of the time period between the onset of decompensated cirrhosis and liver transplantation, death or end of follow-up between the 3 groups (Fig. 4B). Considering the between-group differences in mortality, the distinct duration of the decompensation phase would have been even more marked if follow-up had been longer than 1 year. Prevalence and severity of bacterial infections Table 2 provides information about infections during the 3 months before enrollment, at enrollment and during the 3 months after enrollment. Overall, 178 (22.4%) out of the 796 patients with data developed at least 1 bacterial infection during the 3-month period prior to enrollment. Of the 1,071 patients included in the analysis, 29.3% (n = 314) and 24% (n = 257) had infections at enrollment and during the 3-month follow-up period, respectively. These 571 patients with infections at enrollment or during follow-up (53.3%) presented a total of 674 infections. Considering bacterial infections, Table 2 shows that the distinctive features of patients with pre-ACLF relative to patients of the 2 other groups included a higher proportion of patients with at least 1 infectious episode during the 6-month observational period (see also Fig. 4C); higher proportion of patients with sepsis at enrollment and during follow-up; higher proportion of patients with pneumonia during follow-up; and a higher proportion of patients receiving therapeutic antibiotics; all these differences being significant. During follow-up, the proportion of patients with community-acquired infection was significantly lower among patients with pre-ACLF than among the 2 other groups (Table 2). These findings are consistent with higher prevalence and severity of bacterial infections in the pre-ACLF group. At any time, the proportion of patients with infections caused by multi-drug-resistant bacteria was significantly higher between the pre-ACLF group and the UDC group (Table 2). Clinical features prior to enrollment By definition, patients with pre-ACLF and UDC exhibited greater clinical instability during the first 3 months after enrollment than patients with SDC. However, their clinical courses were also more unstable within the 3-month period prior to enrollment, as indicated by the significantly higher frequency of bacterial infections, ascites or hepatic encephalopathy and, consequently, hospital admissions in these groups of patients (Tables 1 and 2). Clinical features and laboratory data at enrollment and during follow-up Markers of systemic inflammation across groups The WBC count and the CRP levels were significantly higher at enrollment in patients with pre-ACLF than in patients from the other 2 groups (Table 1). In contrast, there were no significant differences in these biomarkers between patients with UDC and SDC. We compared the CRP levels and WBC measured at enrollment in patients with SDC, UDC and pre-ACLF, with those measured at the time of follow-up diagnosis of ACLF in 176 patients from the pre-ACLF group (including 103 patients with ACLF-1, 52 with ACLF-2, and 21 with ACLF-3), and those measured in a control group of 34 patients with compensated cirrhosis (no prior history of AD) (Fig. 4D) previously described. 5,6 Of note, the last 2 groups were included to facilitate the comparison of systemic inflammation throughout the whole spectrum of cirrhosis. There was a progressive increase in the grade of systemic inflammation across the different groups. We also performed within-group comparisons of the levels of inflammatory markers measured at enrollment vs. those measured during follow-up (Table 3). The follow-up timepoint was the time of diagnosis of ACLF for the pre-ACLF group, while for the other 2 groups of patients, it was the last measurement prior to liver transplantation, or death, or the end of the 3-month Cumulative incidence function of death 1.0 0.8 0.6 0.4 0.2 0.0 90 120 150 180 210 240 270 300 330 360 Days Gray’s test p <0.0001 Pre-ACLF group UDC group SDC group Cumulative percentage of ACLF 100 80 60 40 20 90 70 50 30 10 0 1234567 8 910 11 12 13 Weeks between inclusion and ACLF development A B Fig. 3. Cumulative rates of ACLF and death. (A) Cumulative rate of ACLF per week during the 90-day follow-up period in patients with pre-ACLF. (B) Cumulative incidence of death between the 90-day (landmark) and 1 year after enrollment in patients with pre-ACLF, UDC and SDC. ACLF, acute-on-chronic liver failure; SDC, stable decompensated cirrhosis; UDC, unstable decompensated cirrhosis. 848 Journal of Hepatology 2020 vol. 73 j842–854 Research Article Cirrhosis and Liver Failure follow-up period. Within each group, there was a close relationship between changes in inflammatory markers and the clinical course (Table 3). Progression of AD to ACLF in the pre- ACLF group occurred in the setting of a significant increase in WBC count and serum concentration of CRP. In patients with UDC there were no significant changes in WBC count and a small, but significant decrease in CRP, suggesting minor improvement of systemic inflammation. Finally, patients with SDC had a significant reduction in WBC and PCR. Association between systemic inflammation and complications that define AD In order to assess the association between systemic inflammation and the 3 major complications that define AD, we explored 134 patients who had no prior history of AD and were enrolled only for ascites (n = 99), encephalopathy (n = 14) or gastrointestinal hemorrhage (n = 21). The median (IQR) levels of plasma CRP was remarkably higher (p<0.002) in patients with ascites (23.4 [12.5–38.0]) than in those with encephalopathy (11.0 [4.4–21.6]) and gastrointestinal hemorrhage (5.0 [3.0–22.4]) (Fig. 4E). Organ function and scores The prevalence of liver failure, liver dysfunction and renal dysfunction (as defined by the CLIF-C OF score 11 ) at enrollment was significantly higher among patients with pre-ACLF group than among those with UDC and SDC (Table 1). Moreover, laboratory measurements estimating liver and renal function at enrollment were significantly more impaired among patients with pre-ACLF than among those with UDC and SDC, suggesting that a significant deterioration of organ function existed prior to enrollment in patients with pre-ACLF. CLIF-C AD and MELD-sodium scores significantly worsened during the progression of pre-ACLF to ACLF and improved in AB 0306090 Months 12 (6; 26) 14 (10; 24) 20 (11; 41) Pre-ACLF UDC SDC p = 0.01 p = 0.04 p <0.001 Pre-ACLF UDC SDC 010 30 5020 40 60 Months Percentage 80 60 40 20 70 50 30 10 0 Pre- ACLF C72.5 57.5 40.5 p <0.001 p <0.001 UDC SDC CRP (mg/L) 45 35 25 10 40 30 15 5 0 20 Pre-ACLF Dp <0.001 SDC CC UDC ACLF CRP (mg/L) 100 80 60 20 0 40 p = 0.002 HEAscites GIB EF Percentage 50 40 25 15 45 30 20 5 0 35 10 27.1 44.6 31.3 p <0.001 p <0.001 UDC SDC Pre- ACLF Fig. 4. Liver transplantation or death, as well as surrogates of systemic inflammation and portal hypertension in patients with pre-ACLF, UDC and SDC. (A) Density curves of liver transplantation or death during the 1-year follow-up period after enrollment in patients with pre-ACLF (in red), UDC (in blue) and SDC (in green) taking the zero-point as the onset of acute decompensation. The median time (IQR) from the onset of clinically decompensated cirrhosis (as defined by the date of first the episode of acute decompensation) to death or liver transplantation (duration of the decompensated phase of cirrhosis) was significantly shorter in patients with pre-ACLF than in those with UDC, and in patients with UDC than in those with SDC. pvalues were obtained using Mann-Whitney Utest. (B) Individual time period between the onset of decompensated cirrhosis and liver transplantation, death or the end of the 1-year follow-up period after enrollment in the 3 groups of patients. For clarity, the figure does not include patients with values over the 75% IQR. Differences between groups were highly significant (p <0.001). pvalues were obtained using Kruskal-Wallis test. (C) The percentage of patients developing at least 1 bacterial infection during the 6-month observational period in patients with pre-ACLF, UDC and SDC. pvalues were obtained using chi-square test. (D) Plasma levels of CRP (median and 75% CI) in a control group of 34 patients with compensated cirrhosis (CC, no prior history of AD), SDC, UDC, pre-ACLF and ACLF. Patients with CC were studied previously. 5,6 The ACLF group includes 176 patients from the pre-ACLF group who develop ACLF during the 3-month follow-up period. Samples for PCR measurements in these patients were obtained at the time of ACLF development, pvalues were obtained using Kruskal-Wallis test. (E) Serum concentration of C-reactive protein in 134 patients without prior history of AD who were enrolled only for ascites, encephalopathy or gastrointestinal hemorrhage. pvalues were obtained using Kruskal-Wallis test. (F) Percentage of patients presenting at least one surrogate of severe portal hypertension during the 6-month observational period in the Pre-ACLF, UDC and SDC groups. Pvalues were obtained using chi-square test. ACLF, acute-on-chronic liver failure; AD, acute decompensation; CC, compensated cirrhosis; CRP, C-reactive protein; SDC, stable decompensated cirrhosis; UDC, unstable decompensated cirrhosis. Journal of Hepatology 2020 vol. 73 j842–854 849