A Validation Cohort for ACLF Diagnosis and Prognosis
A Validation Cohort for ACLF Diagnosis and Prognosis
Acute on chronic liver failure (ACLF) is a distinct entity encompassing the acute
 deterioration of liver function, culminating in multiple organs failure and high short-term
 mortality. Definitions and descriptions of ACLF vary between Western and Eastern types, and
 alcoholism and hepatitis B virus (HBV) are the main etiologies, respectively. To determine
 whether there are unified diagnostic criteria, severity classification and prognostic model
 for different etiologies of ACLF. Investigators had launched a multicenter prospective cohort
 with the same inclusion criteria and disease indicators as those used in the European CANONIC
 (Chronic liver failure-ACLF in Cirrhosis) study in China，the Ch-CANONIC study(NCT02457637).
 From Jan 2015 to Dec 2016, 2,600 inpatients with chronic liver disease complicated with ALI
 and/or AD were recruited. Data were collected during a 28-day hospitalization and continuous
 follow-ups were performed once a month until 36 months after hospitalization (at least 18
 months up to now). Of these patients, 71.5% had HBV-related disease, 1833 had cirrhotic
 disease, and 767 had non-cirrhotic disease diagnosed by CT scan.

 Due to the lack of pathological gold standards, the diagnosis of ACLF is based on the
 clinical assessment of short-term mortality from organ functional parameters. In subsequent
 statistics and data analysis, investigators focused on (but not limit in) the relationship
 between short-term mortality and 6 parameters (bilirubin, INR, Creatinine, SpO2/FiO2, mean
 arterial pressure and West-Haven grade) from CLIF-C OFs (Chronic liver failure-Consortium
 Organ Failure score). And then a specific mathematical model has been constructed to obtain
 the available organ failure cutoff values. Subsequently, investigators carried out a
 diagnostical criteria for ACLF based on the results obtained from the model and get a good
 internal-validation result through risk ratio. Meanwhile, investigators conducted a precise
 prediction model for patients' prognosis and achieved a good predictive effect with
 consistency by AUC internal-validation. In addition, investigators summarized the course and
 some characteristics of ACLF.

 Therefore, investigators hope to launch another prospective multi-center cohort study with
 the same inclusion and exclusion criteria, and continue to recruit 800 to 900 patients (about
 30% of the previous cohort) as the external validation cohort for the preliminary results
 mentioned above.
Acute-on chronic liver failure (ACLF) was first described by Japanese researchers in 1995. In
 2011, the American Association for the Study of Liver Disease (AASLD) and the European
 Association for the Study of the Liver (EASL) concluded that the core characteristics of ACLF
 were multiple organ failures and high short-term mortality. In 2013, the EASL-CLIF (the
 European Association for the Study of The Liver-chronic liver failure) established the
 CLIF-SOFA (chronic liver failure-sequential organ failure assessment) criteria of ACLF
 through a prospective multicenter study at 29 liver units in eight European countries for 1
 year, with a focus on patients with alcoholic cirrhosis with acute decompensation (AD). In
 the Asia-Pacific region, the majority of liver disease is viral hepatitis, while in western
 countries, it is alcoholic liver disease. There is a sharp east-west divide with respect to
 the definition of ACLF, especially in the definition of chronic liver disease and related
 organ failure.

 In 2014, investigators had analyzed 6 years' data of hepatitis B virus (HBV)-related chronic
 liver disease in patients with AD in two affiliated hospitals of Shanghai Jiao Tong
 University School of Medicine. These data were also quantified and sent to the EASL-CLIF
 center for analysis. 80% of whole patients were clinically diagnosed with cirrhosis, 30% of
 which had pathological diagnosis. Through analysis of the liver tissues of the liver
 transplantation (LT) patients, 95% had pseudo-lobules. The residual 5% of liver tissues were
 in the S3 stage of progressive liver fibrosis. Moreover, the research also demonstrated that
 the pathological characteristics of ACLF may be MHN/SMHN (massive hepatic necrosis/submassive
 hepatic necrosis) in the background of liver pseudo-lobules. Regeneration of hepatic
 progenitor cells, cholestasis, and sepsis are other possible pathological features of ACLF.

 Compared with the CANONIC (EASL-CLIF Acute-on-Chronic Liver Failure in Cirrhosis), there are
 many similarities between ACLF patients with alcoholic cirrhosis or HBV induced cirrhosis.But
 ACLF patients with cirrhosis induced by HBV or alcoholism differ in main types of organ
 failure. According to CLIF-C OFs (CLIF-C organ failure score), the incidence of 6 organ
 failures is not exactly the same in the two types of ACLF. Even for the same type of organ
 failure, the short-term mortality of patients is different.

 To determine whether there are unified diagnostic criteria, disease grades classification and
 prognostic model for different etiologies of ACLF, Investigators had launched a multicenter
 prospective cohort with the same inclusion criteria and disease indicators as those used in
 the European CANONIC study in China，the Ch-CANONIC study (NCT02457637). The research was
 carried out in 14 Chinese national wide liver centers each of whose total beds are around
 500. From Jan 2015 to Dec 2016, 2600 inpatients with chronic liver disease (including chronic
 liver hepatitis patients without cirrhosis, compensated cirrhosis patients, decompensated
 cirrhosis, non-alcoholic fatty liver disease or alcoholic liver disease patients) complicated
 with AD [acute decompensation): including [(having ascites, hepatic encephalopathy, bacterial
 infection, gastrointestinal bleeding or jaundice (TB>5NL) within 1 month before enrollment]
 and/or ALI [acute liver injury: including ALT>3NL (normal level), AST>3NL or TB>2NL within 1
 week before enrollment] were recruited. Data were collected during a 28-day hospitalization
 and continuous follow-ups were performed once a month until 36 months after hospital
 discharge. Of these patients, 71.5% (1859/2600) had HBV-related disease,71.5% (1833/2600) had
 cirrhotic disease, and 28.5% (767/2600) had non-cirrhotic disease.

 Up to now, every recruited patient has been followed-up for at least 18 months. Thus, a large
 amount of data has been collected for analysis. The preliminary results of our research are
 as follows (As the relevant papers are being reviewed, the detailed data will be updated in
 subsequent protocols):

 1. Investigators explored the epidemiology of inpatients with severe chronic liver disease
 and the risk of high short-term mortality in nationwide hospitals, including the
 prevalence of acute deterioration, the disease burden and the clinical features of
 patients with short-term mortality.

 2. Investigators had got some conclusions from many observations of the clinical course of
 patients with short-term mortality. The time interval from acute insults to different
 endpoints, including AD, organ failure and death was carefully evaluated. Moreover, the
 distribution and regularity of mortality within a one-year follow-up had also been
 plotted.

 3. Due to the lack of pathological gold standards, the diagnosis of ACLF is based on the
 clinical assessment of short-term mortality from organ functional parameters.
 Investigators implemented a statistical approach to determine cut-off values for vital
 organ damage and failure. In subsequent statistics and data analysis, refer to the
 CANONIC study, at the beginning investigators focused on (but not limit in) the
 relationship between short-term mortality and 6 parameters (bilirubin, International
 Normalized Ratio, Creatinine, SpO2/FiO2, mean arterial pressure and West-Haven grade)
 from CLIF-C OFs. And then a specific an evidence-based model has been constructed to
 obtain the available organ failure cutoff values. Subsequently, investigators
 established a diagnostical criteria for ACLF based on the results obtained from the
 model to quantify the severity of the disease.

 4. A prognosis model was established to define high disease risk patients to distinguish
 early-stage ACLF patients (pre-ACLF) from non-ACLF patients with AD or ALI.
 Investigators achieved a good predictive effect with consistency by AUC
 internal-validation.

 5. Implementation of high-throughput screening by proteomic and metabolomic studies to
 screen and validate biomarkers for the prediction of ACLF in the early stage and
 establish a prognostic evaluation for ACLF using plasma from a biobank; execution of a
 Genome-wide Association Study (GWAS) using DNA samples extracted from peripheral blood
 mononuclear cells; and exploration of the mechanism of ACLF disease progression by
 studying DNA levels (GWAS), protein levels (proteomic analysis) and metabolite levels
 (metabolomic analysis). This part of work is in progress.

 Therefore, investigators hope to launch another cohort study with the same
 inclusion/exclusion criteria and recruit 800-900 patients (about 30% of the previous cohort)
 as the external validation cohort for the preliminary results (1~4) mentioned above.

 Overall, 800-900 inpatients will be enrolled continuously from Sep. 2018 to Mar.
 2019(anticipated). The research will be carried out in about 12 Chinese national wide liver
 centers each of whose total beds are around 500. Every patient will have a unique number.
 Cirrhosis or non-cirrhosis will be diagnosed by CT, FibroScan and FIB-4 index. The
 investigators will take the note of the history of their liver disease and find the etiology
 of their liver disease, such as hepatitis B, NAFLD, alcoholic liver disease, and autoimmune
 liver disease. For viral hepatitis, the investigators will ask how antiviral therapy is
 conducted. The investigators will ascertain if the patients have a history of cirrhosis and
 for how long. The investigators will ascertain if the patients have any of the following
 predisposing factors: HBV reactivation, bacterial infection, active alcohol intake, HBV
 superimposed by other hepatitis viruses, gastrointestinal bleeding, portal vein thrombosis,
 surgery, intake of hepatotoxic drugs or herbs, or physiological exhaustion. The investigators
 will establish the main cause of admission: gastrointestinal bleeding, hepatic
 encephalopathy, ascites, bacterial infection, jaundice or ALI. The investigators will
 determine whether the patients have chronic disease such as hypertension, coronary heart
 disease, diabetes, chronic renal disease, or connective tissue disease.

 During hospitalization, data will be collected at 1, 7,14, 21 and 28 days (or last visit
 date, if the patient is hospitalized less than 28 days), and 24h prior to death or LT (if the
 patient dies or has LT) and focus on the following three aspects.

 The first aspect is evaluation of organ failure. The circulatory system will be evaluated by
 measuring heart rate and blood pressure and use of vasopressors. Renal function will be
 evaluated by serum creatinine or renal replacement therapy. Coagulation function will be
 evaluated by INR (international normalized ratio of prothrombin time). Liver function will be
 evaluated by serum total bilirubin. The respiratory system will be evaluated by the
 oxygenation index (SpO2/FiO2), and whether the patient needs nasal catheter oxygen and
 artificial ventilation will also be recorded. The nervous system will be evaluated by the
 West-Haven grade of hepatic encephalopathy. Bacterial infection, including pneumonia, urinary
 tract infection, spontaneous bacterial peritonitis, spontaneous bacteremia, and cellulitis
 will be evaluated by positive culture results or imaging findings.The investigators will
 establish whether ascites and hepatic encephalopathy can be medically controlled.

 The second aspect is laboratory examinations. Tests at admission will include routine blood,
 urine and stool tests, liver and renal function tests, blood electrolytes, blood-gas
 analysis, blood glucose, coagulation test, C-reactive protein (CRP), procalcitonin (PCT), HBV
 antibodies and antigens, anti-hepatitis A (IgM), HBV-DNA, anti-hepatitis E (IgM),
 anti-hepatitis C, and immunoglobulins (IgA, IgG, IgM and IgM-4). Tests at other times will
 include blood, urine and stool routine tests, liver and renal function tests, blood
 electrolytes, blood glucose, coagulation test, CRP (C-reactive protein) and PCT
 (procalcitonin). Tests optionally done during hospitalization will include autoantibody
 measurement. Blood，sputum，ascites culture or middle urine cultivation will be taken if a
 patient is suspected of having a relevant infection.

 The third aspect is imaging. During hospitalization, thoracic X ray or computed tomography
 (CT) will be done to diagnose pulmonary infection. Abdominal CT (enhanced when necessary), B
 ultrasound and FibroScan or other elastography will be done to diagnose cirrhosis (or
 fibrosis), portal thrombosis, esophageal and gastric varices and hepatocellular carcinoma.

 Follow-up will be clinical visiting, but telephone call will be acceptable for patients
 unable to attend. Clinical follow-up is once a month for 3 months adding to 3 visits.
 Laboratory tests should be taken at least once (the last visit is perferred) including
 routine blood tests, liver and renal function test, coagulation test, CRP and PCT. B
 ultrasound will be done to monitor cirrhosis (or fibrosis) , complications and hepatocellular
 carcinoma. During follow-up, patients will be hospitalized again whenever they have new ALI
 or AD. Similar data will be collected reference to their prior admission and follow-up will
 restart. If the patients die during follow-up, the time of death and main cause of death will
 be noted. When the patients undergo LT during follow-up, the time of LT and the results of
 hepatic pathology will be noted.

 Demographic data, disease history, baseline data after admission and follow-up data after
 discharge will be recorded in a similar process and quality control. But investigators plan
 to simplify some data collection work. Concretely, (1) During hospitalization, data will be
 recorded and followed up once a week (but must include the first and last day's data of
 hospitalization).(2) Samples of feces and urine are no longer collected. (3) The duration of
 follow-up for each discharged patient will be shorten from 36 months to 3 months.
Inclusion Criteria:

 -  inpatient (hospitalization >1 days)(including patient in emergency observation
 wards)chronic liver disease patients including non-alcoholic fatty liver disease
 patients,chronic liver hepatitis patients without cirrhosis, compensated cirrhosis
 patients and decompensated cirrhosis patients

 -  having acute liver injury [ALT(alanine aminotransferase)>3ULN,AST(aspartate
 aminotransferase)>3ULN or TB(total bilirubin)>2 ULN within 1 week before enrollment]
 or acute decompensation[having ascites, hepatic encephalopathy, bacterial infection
 ,gastrointestinal bleeding or jaundice(TB>5NL)within 1 month before enrollment].

 Exclusion Criteria:

 -  pregnancy

 -  hepatocellular carcinoma or other liver malignancies

 -  malignancy of other organs

 -  severe chronic extrahepatic disease including chronic obstructive pulmonary disease
 combined with respiratory failure, coronary heart disease with cardiac function level
 3 (NYHA), myocardial infarction in the 3 months before admission, diabetes with severe
 complications and chronic kidney disease with end-stage renal failure receiving
 immunosuppressive drugs for reasons other than chronic liver disease