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Acute Liver Failure: Time to Review Our Follow-Up Policy?

| Hepatology
Authors:
*Mhairi C. Donnelly, Kenneth J. Simpson
Disclosure:

The authors have declared no conflicts of interest.

Acknowledgements:

The authors would like to thank the Chief Scientist Office, Edinburgh, UK for funding this project and the Electronic Data Research and Innovation Service (eDRIS), Edinburgh, UK for providing the secure research database.

Citation
EMJ Hepatol. ;6[1]:59-60. Abstract Review No. AR4.

Each article is made available under the terms of the Creative Commons Attribution-Non Commercial 4.0 License.

Acute liver failure (ALF) is a rare but serious clinical condition resulting from sudden, massive loss of hepatic parenchyma and metabolic functions. In the UK, ALF is estimated to affect 1–8 people per 1 million population.1 In Scotland, UK, all patients with severe acute liver injury or ALF are managed in a single national centre: the Scottish Liver Transplant Unit (SLTU). Here, the patient is managed supportively until effective liver regeneration occurs or until liver transplantation, if this is deemed necessary and the patient is a suitable candidate. The assumption has long been that if an ALF patient survives without liver transplantation (a group known as spontaneous survivors [SS]), they return to healthy liver function and experience no lasting associated morbidity and mortality. However, results of two recent studies have suggested that this assumption may not be true.2,3

Our research group aimed to evaluate long-term healthcare use (as a surrogate marker for morbidity) of ALF SS following discharge from their index hospital admission with ALF and to compare this with the healthcare resource use of an age, sex, and postcode-matched sample of the general Scottish population. Studies have previously shown an increase in mortality in SS of ALF compared with this matched control cohort. The study cohort of ALF SS consisted of >700 patients admitted between November 1992 and December 2014 who survived to hospital discharge without transplantation. The matched control cohort was composed of >3,400 matched healthy controls from the general Scottish population.

Overall, it was found that the SS of ALF utilised a significant amount of healthcare resources following discharge from their index hospital admission with ALF. By 20 years of follow-up, >90% of patients had required a readmission to hospital. The majority of these readmissions were unscheduled emergency admissions and were associated with the majority of days spent in hospital and the accompanying healthcare costs. The total cost for all hospital admissions in the SS of ALF cohort exceeded £9 million. Predictors of the number of readmissions in the SS of ALF cohort were identified and included age, aetiology of ALF, and the number of admissions to hospital in the preceding 5 years.

Comparing the healthcare resource use of the SS of ALF and the matched controls, the cumulative incidence of readmission was significantly higher in the SS of ALF cohort than the matched controls, continuing from 30 days post discharge to 20 years of follow-up. Overall, the SS of ALF were 50% more likely to experience any readmission and over twice as likely to experience an emergency readmission. Considering the health economics impact, the SS of ALF accrued an excess cost of >£9,000 per 10 person-years compared to the control cohort.

Identifying the causes of readmissions in SS of ALF will be important to guide the development of follow-up and review strategies. The main cause of readmission may be medical or psychiatric, both of which would require different follow-up protocols. It should be noted that the majority of ALF patients in this study (>80%) had paracetamol-induced ALF and the causes of readmission may be different between the paracetamol and non-paracetamol-induced ALF cohorts. Within the non-paracetamol cohort, the number and cause of readmissions may vary between different ALF aetiologies; however, the number of patients in this current study is too small to draw any significant conclusions. Our work suggests that any new follow-up strategy should initially focus on those patients identified to be at a high risk of readmission. In time, we hope that our work will help reduce the burden, both in terms of morbidity and mortality, of surviving ALF.

References
Bernal W et al. Acute liver failure. Lancet. 2010;376(9736):190-201. Jepsen P et al. Long-term prognosis for transplant-free survivors of paracetamol-induced acute liver failure. Aliment Pharmacol Ther. 2010;32(7):894-900. Fontana RJ et al. 2-year outcomes in initial survivors with acute liver failure: Results from a prospective, multicenter study. Liver Int. 2015;35(2):370-80.