Retrospective Cohort Study
Copyright ©The Author(s) 2021. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Jun 21, 2021; 27(23): 3372-3385
Published online Jun 21, 2021. doi: 10.3748/wjg.v27.i23.3372
Effect of type 2 diabetic mellitus in the prognosis of acute-on-chronic liver failure patients in China
Rui-Min Lai, Tian-Bin Chen, Yu-Hai Hu, Gui Wu, Qi Zheng
Rui-Min Lai, Yu-Hai Hu, Qi Zheng, Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, Fujian Province, China
Tian-Bin Chen, Department of Laboratory Medicine, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, Fujian Province, China
Gui Wu, Department of Orthopedics, The First Affiliated Hospital, Fujian Medical University, Fuzhou 350005, Fujian Province, China
Author contributions: Lai RM and Chen TB contributed equally to this work; Lai RM, Chen TB, and Zheng Q conceived and designed the study; Chen TB analyzed the data; Hu YH and Wu G collected clinical data of the patients; Lai RM and Zheng Q wrote the manuscript; all authors read and approved the final version of the manuscript.
Supported by Fujian Health Research Talents Training Program, No. 2019-1-42; National Natural Science Foundation of China, No. 81702073; and Fujian Provincial Natural Science Foundation General Project, No. 2020J01955.
Institutional review board statement: This study was approved by the Institutional Review Board of Fujian Medical University.
Informed consent statement: Patients were not required to give informed consent to the study because the analysis used anonymous data that were obtained after each patient agreed to treatment by written consent.
Conflict-of-interest statement: All the authors have no conflict of interest related to the manuscript.
Data sharing statement: The original anonymous dataset is available on request from the corresponding author at bei0825@163.com.
STROBE statement: The authors have read the STROBE Statement-checklist of items, and the manuscript was prepared and revised according to the STROBE Statement-checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Qi Zheng, PhD, Professor, Department of Hepatology, Hepatology Research Institute, The First Affiliated Hospital, Fujian Medical University, No. 20 Chazhong Road, Taijiang District, Fuzhou 350005, Fujian Province, China. bei0825@163.com
Received: January 28, 2021
Peer-review started: January 28, 2021
First decision: April 5, 2021
Revised: April 14, 2021
Accepted: May 20, 2021
Article in press: May 20, 2021
Published online: June 21, 2021
ARTICLE HIGHLIGHTS
Research background

The acute-on-chronic liver failure (ACLF) patients have a high short-term mortality rate, and the severity evaluation of ACLF is necessary for prognostication. The prevalence of diabetic mellitus (DM) has increased significantly in recent decades, resulting in coexistence of DM and chronic liver disease be common. There were very few studies that have evaluated the association between DM and ACLF. Therefore, the association between type 2 DM and the prognosis of patients with ACLF remained unclear.

Research motivation

Previous studies suggested that DM increased higher incidences of complications in chronic liver disease, included encephalopathy, spontaneous bacterial peritonitis, and hepatocellular carcinoma, but it was not clear whether DM would similarly affect ACLF patients. We needed further to evaluate the association between DM and the prognosis of ACLF patients in order to explore the feasibility of using DM as a prognostic indicator in ACLF patients.

Research objectives

We aimed to examine the effect of DM on the prognosis of patients with ACLF and established a predictive model to predict the risk of mortality for ACLF patients. A well-established prognostic predictive model was extremely important, which was helpful for early intervention of ACLF patients as well as improved survival rate.

Research methods

Clinical data from 222 ACLF patients were retrospectively collected and analyzed between July 2013 and July 2020 from the Department of Hepatology Research Institute of the First Affiliated Hospital, Fujian Medical University. The patients were categorized into two groups depending on whether they had DM or not, and complications of ACLF were documented during treatment. Values of laboratory parameters, complication rates, and hospital mortality rates were compared between two groups. The Cox proportional hazard regression analysis was used to estimate hazard ratio (HR) for the association between DM and all-cause mortality. DM was independent risk factor to predict mortality in ACLF patients. Further, the nomogram and forest plot were built in terms of results of Cox regression analyses. A survival nomogram model was constructed to predict the probability of 1- and 2-mo survival for ACLF patients.

Research results

The prognosis of ACLF patients was significantly correlated with DM in univariate (HR = 2.4, P < 0.001) and multivariable analysis (HR = 3.17, P < 0.001). The ACLF patients with DM tended to have a high mortality rate (P < 0.001). Survival curves showed that the cumulative survival rate of ACLF patients was significantly distinguished between DM and non-DM (P = 0.00019). The survival time of ACLF patients with non-DM was longer than the patients with DM. As a good prognostic indicator, DM was helpful to predict the outcome of ACLF patients. The incidence of infection was higher in DM patients than non-DM counterparts (P = 0.038). Among all possible infections, spontaneous peritonitis and pulmonary infection should be considered a priority for ACLF patients. ACLF patients’ survival nomogram could predict the probability of 1- and 2-mo survival, which would be helpful to provide early clinical intervention. Because of the retrospective design of the study, we needed to assess further the impact of DM on the prognosis in ACLF patients by a prospective cohort study.

Research conclusions

Our study found a significant association between DM and the prognosis of ACLF patients in China. The survival time of ACLF patients with non-DM was longer than that of patients with DM. The ACLF patients with DM had higher incidence of hospital mortality and infection than those without DM. DM was an independent risk factor affecting the prognosis of ACLF patients.

Research perspectives

This was not a multicenter study and the number of DM patients with ACLF was relatively small. Therefore, a multi-center prospective cohort study would evaluate further the impact of DM on the prognosis in ACLF patients. Meanwhile, a noninvasive model should be established based on an extensive clinical database to predict effectively the survival time of ACLF patients.