HBV-ACLF is associated with a high mortality[9-11
], although liver transplantation can significantly improve the survival rate[12,13
]. However, liver transplantation is limited by many factors, especially donor shortages; only 11 patients in the current study received a transplant. Improved medical treatment is the key to prolonging the survival of patients with HBV-ACLF. The effects of antiviral treatment with nucleoside analogs on hepatitis B related liver failure is currently a focus of clinical research, but their efficacy remains controversial. Several reports have suggested that lamivudine could significantly improve the prognosis of patients with liver failure[14-17
], but Kumar et al[18
] reported that, although lamivudine significantly decreased the levels of HBV DNA in patients with acute hepatitis B, it did not result in any significant biochemical or clinical improvement, compared with patients receiving a placebo. In the current study, survival analysis showed that the mortality of patients who received nucleoside analog (entecavir or lamivudine) therapy was significantly lower than that of patients who did not receive antiviral drugs. This indicates that treatment with nucleoside analogs (lamivudine/entecavir) could improve the prognosis of patients with HBV-ACLF, and suggests that nucleoside analog therapy should be implemented in these patients as soon as possible.
In addition to antiviral therapy, other factors were found to significantly influence the prognosis, including HE, electrolyte imbalance, and HRS. Methods for treating and preventing the complications of HBV-ACLF remain important research topics. Yu et al[19
] found that, in HBV-ACLF patients treated with lamivudine and plasma exchange, multivariate analysis identified a MELD score of 30-40 or > 40 to be a good predictor of treatment outcome. The present study, however, found no significant effect of MELD score on prognosis. However, the P
value of 0.053 suggests that a MELD score > 30 might predict a poorer prognosis in patients with HBV-ACLF if a larger sample size was analyzed. Thus, although pretreatment HBV DNA levels and MELD score had no significant effects on patient survival in this study, further studies using larger samples, or multicenter trials, are required to confirm these results.
HBV-ACLF, although rare, remains a rapidly progressive and frequently fatal condition. Traditional treatment is generally supportive, and HE, HRS and electrolyte disturbances remain the leading causes of death. In China, liver injury is caused mostly by hepaciviruses (especially HBV)[20
] and may therefore be preventable. Clinicians should be aware of the rapid evolution of liver failure, and the possible risks for patients who develop any degree of coagulopathy and encephalopathy. Because the outcome is unpredictable, early transfer to a transplantation facility should be considered before the onset of advanced grades of coma, after which transfer becomes impossible. Further understanding of the pathophysiologic characteristics of this multisystemic condition and the development of better supportive therapies should improve the outcome of patients with HBV-ACLF.