Meeting the Eastern perspective in hepatitis B related ACLF.

Chronic hepatitis B (CHB) related liver disease affects millions of patients worldwide,1 and acute decompensation superimposed on cirrhosis, now termed acute-on-chronic liver failure (ACLF) has a high short-term mortality, and acute reactivation of CHB frequently sets off ACLF. Effective viral suppression and liver transplantation are the mainstays of management. From both a clinical and public health perspective, accurate prediction of patients at highest risk of decompensation and thus most likely to benefit from expensive and scarce resources is highly valuable. Use of the Model for End-stage Liver Disease (MELD) score to determine liver transplantation need has become ingrained as the de facto method for establishing short-term mortality in patients with chronic liver disease since its institution in the US transplant system in 2002; however, many refinements have been suggested to address the imperfections of MELD, which is appropriate given that the face of cirrhosis and chronic liver disease will continue to change as clinical advances arise in the care of these patients. The authors of this article evaluate several outcome/mortality prediction models in CHB-related ACLF by comparing iterations of MELD in a cohort of 232 Chinese patients with CHB who participated in a previous study of an acute liver decompensation assist device system.2 These alternate versions of MELD include additional parameters of clinical care as well as previously validated prediction methods, including Child-Turcotte-Pugh (CTP) score. Using sophisticated statistical methodology, the authors conclude that integrated MELD, or iMELD, which incorporates age and sodium along with the traditional MELD score, is the most robust model to predict shortand long-term mortality. The authors also speculate that refinement of the CTP score with additional parameters may improve its applicability (CTP-based model was modified by extending scoring to 18 points via an additional stratification for more elevated laboratory values). Most significantly, the authors suggest that predictive models like MELD, iMELD, MELD-Na, and others may need to be re-examined in selected populations given that origination, specification, and validation of the models were done using predominantly Caucasian populations from the US and Europe, which may introduce ethnic/genetic-based biases, biases related to differences in the prevalence of various etiologies of liver disease (i.e. CHB prevalence is higher in Asia but less in Europe and North America), as well as differences due to treatment effects across geographic regions. Many of the authors’ results and conclusions point to an “East-West divide” in liver disease demographics, etiologies, and treatments when considering past studies that originated and validated several of the most commonly used models. This is a reasonable concern given that the results of clinical studies are only as generalizable as the population studied. In this article, the foundational definitions and analyses used present a few problems related to generalizability to chronic liver disease patients both outside and inside China. The study group’s use of the Chinese Society of Hepatology definition of ACLF is unique and likely constrained by inclusion criteria inherent to the original study of the acute liver assist device, but that would be an issue with any paper as the definition is not uniform across regions. This represents an East-West discrepancy and perhaps deserves a collaborative approach among the major hepatology societies