Incidence, predictors and outcomes of acute on chronic liver failure in outpatients with cirrhosis

Background and aims: Acute-on-chronic liver failure (ACLF) is the most life-threatening complication of cirrhosis. Prevalence and outcomes of ACLF have been recently described in hospitalized patients with cirrhosis. However, no data is currently available on the prevalence and the risk factors of ACLF in outpatients with cirrhosis. The aim of this study was to evaluate incidence, predictors and outcome of ACLF in a large cohort of outpatients with cirrhosis. Methods: Consecutive patients admitted to the outpatients clinic of the University Hospital of Padova from 2003 to 2014 were included and followed up until death and/or liver transplantation for ameanof 48months.Data ondevelopment of hepatic andextrahepatic organ failures were collected during this period. ACLF was defined and graded according to the EASL-CLIF Consortium definition. Results:416patients (69%male,meanage55years)with cirrhosis were included. At inclusion, most of them had ascites (57%) and oesophageal varices (64%).HCVandalcoholwere themost common etiologies (36%and 35%, respectively). Mean MELD score was 12. During the followup106patients (26%)developedACLF, 53grade1, 28 grade 2 and 25 grade 3. The probability to developACLFwas 14%, 29% and48%at 1 year, 5 years and10years, respectively. In themultivariate analysis, age (HR=1.04; p=0.001), baseline mean arterial pressure (HR=0.96; p<0.001), presence of varices (1.66; p=0.041) and MELD score (1.23; p<0.001) were found to be independent predictors of development of ACLF at 5 years. As expected, ACLF was associated with a poor prognosis, with a 3-month probability of transplant-free survival of 57%. Conclusions: Outpatients with cirrhosis have a high probability to develop ACLF. Simple variables such as age, MELD, MAP and presence of varices may help to identify patients with a high risk to develop ACLF and to plan a close program of surveillance and prevention in these patients.