ACLF was a kind of serious disease with mortality about 33% in 28-days[10].But by now,the definition of ACLF was not unified,that may be attributed to the main cause of ACLF was not same in Asia and European.In Asia,HBV infection was the common reason for liver diseases.And due to the long time in HBV infection to liver failure,a window for CHB deteriorate sharply to ACLF existing,which named acute-on-chronic pre liver failure(pre-ACLF)[11],which also means that if we get the key to the alteration of pre-ACLF to ACLF,we may take notice to the patients who has high risk to make progress so that we can improve the bad actuality of this disease.Unfortunately, very few studies have focused on this.Nowadays,many models are explored to evaluate the condition of prognosis of ACLF.In 2020 our country have built a prognostic model named COSSH-ACLF through the database of our HBV-ACLF patients,so which means it suit HBV-ACLF patients better[12].But it includes some subjective indicators(HE,ascites...),espeicially the criteria of HE is also an problem nowadays.So our study evaluate the accuracy of the objective indicators used models including ALBI、MELD、iMELD、MELD-Na score in predicting the severity and short prognosis in ACLF.
With the descriptions of scores in the stages of ACLF,we can make a recognition that the scores can reflect the severity of HBV-ACLF.Among them,the MELD score is the best score in judging.By those results convey to us:if the MELD score > 15.73,the pre-ACLF may have probability in altering to early,middle,late-ACLF(those the real definition of ACLF).But only by virtue of the cut-off value,we cannot make an accurate conclusion.So if we want to reveal the real progressed patients,we need to study the patients in pre-ACLF who make progress into ACLF during 90 daysr[13],but 28 days are more reasonable for HBV-ACLF[14].
As mentioned above,there have an abnormal phenomenon between early-ACLF and middle-ACLF,especially the early-ACLF.The ALBI score in early stage is higher than the middle,which depart from the definition.And the early stage have no suitable score is another abnormal phenomenon.It's worth saying that the cut-off value of middle-ACLF is generally lower than the early-ACLF.Some reason may be explained to this situation:Firstly,the definition of the early-ACLF may not be enough to reveal the character of this stage,especially the limits of complications.It is worth mentioning that the other stage all include the complications even in the pre-ACLF[6].Secondly,we can make attention to the definition of stages,which may tell us answer.As we know,INR have a shorter half-life than the TBIL,which means that TBIL can not reflect the equal condition of INR in the same time.Also,the Kruskal-Wallis test show that TBIL have no significance between early-ACLF and middle-ACLF、late-ACLF, So the limitation of 1.5–1.9 VS 1.9–2.6 VS > 2.6 may have a huge variation in TBIL.And this may be an answer of the no significance of ALBI in the prediction performance.In the future,if we want to make accurate stage of ACLF,We should think this deeply.Or combine the two-stage may be a good resolution,too.Finally,our study sort the early-ACLF with two or more complications into middle-ACLF maybe be another problem as the definition required[6].
As the results conveyed that ALBI with good performance in prognosis and MELD with good performance in assessing the severity.We can make a preliminary decision,the liver synthetic function may be a fatal point in deciding the future of the HBV-ACLF,and the complications were the key of progression of disease,which may be verified by the albumin in the prognosis and Na in the severity[Table1 and Table3].Although sometimes we think the progression of disease has equal mechanism in the the mortality of the disease,but this reminded us they may have different mechanism of action:the progression of disease usually related with the predispositions and the reaction of the body (Immune response, inflammatory response...),so if we took inducement treatments immediately,such as the corticosteroid [15],the patient could have a good prognosis.And what made the patients have a bad prognosis usually have a close relationship of the basement function of the liver:liver have a lot functions,if the injury broken the balance of them,the body would convey a series of disorder in synthesis, metabolism, and immunity...,and liver cells with inefficient regeneration so that the liver manifested in a relatively non-functional state,and progress to death.But what the liver cells go through during the progression manifested and the death on earth and whether they have difference or not need the pathology-related studies.
This study evaluates the current objective scores in the severity and prognosis of HBV-ACLF, but limited to a single center small sample study, some results need to be demonstrated in the future, especially the abnormal phenomenon between the early and middle stage.In addition, this study only compared the defined groups of the stage, we cannot observe the disease progress from one patient with objective conditions. So in the future if want to observe ACLF progress process, the prospective individualized observation was needed.