Background and aims: Acute-on-chronic liver failure (ACLF) is a major public health concern. We aimed to assess the definitions, etiological spectrum, organ failure (OF), and outcomes of ACLF globally.
Methods: Three databases were searched for studies on ACLF from 1990 till September 2022. Information regarding definitions, acute precipitants, underlying chronic liver disease (CLD), OF, and mortality were extracted. Meta-analyses were performed for pooled prevalence rates (95% confidence interval, CI) using random effects model for each definition of ACLF.
Results: Of the 11,451 studies identified, 114 articles (142 cohorts encompassing 210,239 patients) met the eligibility criteria. Most studies (53.2%) used the European Association for the Study of the Liver (EASL) definition, followed by Asia-Pacific Association for the Study of the Liver (APASL) (33.3%). Systemic infection was the major acute precipitant and alcohol use was the major cause of CLD in EASL-defined studies while alcohol was both, the major acute precipitant and cause of CLD in APASL-defined studies. Liver failure was the major OF in APASL-based studies, while renal failure was predominant in EASL-based studies. Thirty-day mortality varied across definitions: APASL: 38.9% [95%CI 31.2-46.9], EASL: 47.9% [95%CI 42.2-53.5] and NACSELD: 52.2% [95%CI 51.9-52.5]. Diagnostic overlap between definitions ranged from 7.7% to 80.2%. Meta-regression suggested that the WHO region influenced 30-day mortality in studies using EASL definition.
Conclusion: Heterogeneity in the definition of ACLF proposed by different expert societies and regional preferences in its use result in differences in clinical phenotype and outcomes. A uniform definition would enhance the comparability and interpretation of global data.
Keywords: ACLF; APASL; Cirrhosis; EASL; NACSELD.
Copyright © 2024. Published by Elsevier Inc.