A Stepwise Evaluation of Hepatitis B Virus-Related Acute-on-Chronic Liver Failure to Optimize the Indication for Urgent Liver Transplantation



Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is a dynamic but reversible disease.


We aimed to clarify whether the change in Chinese Group on the Study of Severe Hepatitis B-ACLF (COSSH-ACLF) grade in HBV-ACLF patients can be used to predict prognosis, and to explore the appropriate conditions for performing urgent liver transplantation.


We assessed the COSSH-ACLF grades of HBV-ACLF patients at different time points from June 2013 to May 2019 at Huashan Hospital in Shanghai, China, and analyzed the relationship between the change in grade and patient prognosis.


A total of 207 HBV-ACLF patients were enrolled, of which 79 underwent urgent liver transplantation. Their COSSH-ACLF grades were calculated at diagnosis, 3–7 days after diagnosis, and on the final day. Most of the final ACLF grades were consistent with their corresponding grades at days 3–7 after diagnosis (62.5%), while only 44.5% were in accordance with the initial grades at diagnosis. In patients who had a poor prognosis (initial ACLF-3 and ACLF-2 or -3 at days 3–7), the 28-day survival rate was 93.3% in those who underwent transplantation and 6.8% in those who did not (P < 0.0001). However, in patients who had a good prognosis (ACLF-0 or ACLF-1 at days 3–7), the 28-day survival rate was 100% in transplanted patients and 91.5% in non-transplanted patients (P = 0.236).


Reevaluation of the COSSH-ACLF grade 3–7 days after diagnosis could potentially show an indication for urgent liver transplantation.

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We would like to thank Brandi from Editage (www.editage.com) for English language editing.


We would like to thank the National Natural Science Foundation of China (No. 81670560) and National Science and Technology Major Project (2017ZX09304005, 2017ZX10202202) for their financial support.

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Correspondence to Yuxian Huang.

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Zhang, X., Ying, Y., Zhou, P. et al. A Stepwise Evaluation of Hepatitis B Virus-Related Acute-on-Chronic Liver Failure to Optimize the Indication for Urgent Liver Transplantation. Dig Dis Sci 66, 284–295 (2021). https://doi.org/10.1007/s10620-020-06149-x

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  • Prognosis
  • Acute-on-chronic liver failure
  • Hepatitis B virus
  • Liver transplantation