Introduction
Acute-on-chronic liver failure (ACLF) is a critical syndrome occurring in individuals with acutely decompensated cirrhosis, characterised by high short-term mortality and multiorgan failure. Accurate prognostic scores are essential to support ICU treatment and outcomes. Socioeconomic status (SES) is a known, independent contributor to ill health and mortality. This study aims to determine if incorporating SES into the CLIF-C ACLF score, a prognostic tool for ACLF outcomes, adds value in predicting in-hospital mortality in patients with ACLF.
Aims & Methods
Data from consecutive patients admitted to the Royal Free London ICU with a complication of cirrhosis, between 2016 and 2017, were obtained from the Royal Free NHS Trust database. CLIF-C ACLF scores were calculated at day 0 and 2 of ICU admission and in-hospital survival was assessed. SES was determined using the English Indices of Deprivation, a validated government tool that utilises individual postcodes to infer a deprivation decile. A higher decile indicates a higher SES and vice versa. Multiple logistic regression was used to examine the joint association between both CLIF-C ACLF and SES upon in-hospital mortality.
Results
The cohort comprised of 851 patients, of which 131 patients have been analysed thus far. There is no significant difference in age or sex between mortality groups (Table 1). Regression analysis showed that SES proves a statistically significant improvement to the CLIF-C ACLF score in predicting in-hospital mortality at day 0 and 2 of ICU admission (p-value = 0.048 and p-value = 0.041, respectively). Additionally, the odds ratios demonstrated a significant inverse relationship between SES and in-hospital mortality, with an odds ratio of 0.847 (95% CI: 0.718 to 0.999) at day 0 and 0.821 (95% CI: 0.664 to 0.992) at day 2.
| Dead | Alive |
|
|
| n | Mean ± SD | n | Mean ± SD | Test used | p-value |
| Age | 48 | 55.8 ± 12.3 | 83 | 53.3 ± 15.0 | Independent T-Test | 0.317 |
| CLIF-C ACLF D0 | 48 | 59.9 ± 11.2 | 83 | 50.1 ± 9.74 | Independent T-Test | <0.001 |
| CLIF-C ACLF D2 | 32 | 64.9 ± 10.2 | 55 | 50.5 ± 11.3 | Independent T-Test | <0.001 |
| Delta (D0 to 2) | 32 | 0.125 ± 9.36 | 55 | -2.49 ± 7.61 | Independent T-Test | 0.163 |
| | n | Median (IQR) | n | Median (IQR) | Test used | p-value |
| Deprivation Decile | 48 | 3.5 (2 - 6.25) | 83 | 5 (3 - 7) | Mann-Whitney U Test | 0.054 |
| n | Male/Female | n | Male/Female | Test used | p-value |
| Sex | 48 | 27/21 | 83 | 54/29 | Chi-Squared Test | 0.317 |
Table 1: Multiple analyses comparing in-hospital mortality groups.
Conclusion
Our findings suggest SES can add predictive value to the CLIF-C ACLF score with regards to in-patient mortality, allowing acute care clinicians to more accurately risk stratify patients in ICU. These findings may also have implications for public health strategies for targeting primary and secondary prevention schemes. Validation in larger cohorts is justified.
References
Engelmann, C., Thomsen, K.L., Zakeri, N., Sheikh, M., Agarwal, B., Jalan, R. and Mookerjee, R.P. (2018). Validation of CLIF-C ACLF score to define a threshold for futility of intensive care support for patients with acute-on-chronic liver failure. Critical Care, 22(1). doi:https://doi.org/10.1186/s13054-018-2156-0.
Moreau, R., Jalan, R., Gines, P., Pavesi, M., Angeli, P., Cordoba, J., Durand, F., Gustot, T., Saliba, F., Domenicali, M., Gerbes, A., Wendon, J., Alessandria, C., Laleman, W., Zeuzem, S., Trebicka, J., Bernardi, M. and Arroyo, V. (2013). Acute-on-Chronic Liver Failure Is a Distinct Syndrome That Develops in Patients With Acute Decompensation
of Cirrhosis. Gastroenterology, 144(7), pp.1426-1437.e9. doi:https://doi.org/10.1053/j.gastro.2013.02.042.
Hernaez, R., Solà, E., Moreau, R. and Ginès, P. (2017). Acute-on-chronic liver failure: an update. Gut, [online] 66(3), pp.541–553. doi:https://doi.org/10.1136/gutjnl-2016- 312670.
