Background & Aims: Acute-on-chronic liver failure (ACLF) is characterized by a rapid progression to multiple organ failure and is associated with a very high mortality rate of 50-90%. Novel therapies are being investigated such as Erythropoietin (EPO). The aim of this prospective cohort study was to analyse the value of EPO in predicting prognosis and determine which patients may benefit most from EPO therapy.

Methods: According to the EASL-CLIF criteria, 104 consecutive patients were diagnosed with ACLF, and separated into two groups based on the type of insult: bleeding (Group A=31) or non-bleeding (Group B=73). In addition to a complete biochemical work-up and calculation of relevant prognostic scores, levels of EPO were measured on admission and correlated to the type of insult and final outcome.

Results: Fifteen patients from Group A (mean age 60.32±9.29 years) had a lethal outcome and higher values of EPO on admission (319.26±326.58 mIU/ml) (p<0.005), compared to the 37 patients from Group B (mean age 59.9±10.19 years) with EPO levels at admission of 29.88±34.6 mIU/mL. In Group B, a cut-off EPO value of 30.65 mIU/mL had a sensitivity of 87.5% and a specificity 57.4% in predicting lethal outcome with an AUROC of 0.823. In Group A, a cut-off value of 229.95 mlU/mL had a sensitivity and specificity of 53.3% and 92.7%, respectively. The AUROC for this cut-off was 0.847.

Conclusions: Erythropoietin is superior to the standard prognostic scores in predicting 28-day mortality. Lower levels of EPO were detected in patients without bleeding as an insult indicating a possible therapeutic benefit in these patients.

Abbreviations: ACLF: acute-on-chronic liver failure; ALD: alcoholic liver disease; APACHE II: acute physiology and chronic health evaluation II; AUROC: Area Under the Receiver Operating Curve; CLD: chronic liver disease; CLIF: Chronic Liver Failure Consortium; CLIF-SOFA: Chronic Liver Failure Consortium-Sequential Organ Failure Assessment; CTP: Child-Turcotte-Pugh; EPO: erythropoietin; GI: gastrointestinal; HBsAg: hepatitis B surface antigen; MARS: Molecular Adsorbent Recirculating System; MELD: Model for End Stage Liver Disease; MELD Na: Model for End Stage Liver Disease Sodium; SOFA: Sequential Organ Failure Assessment.


acute-on-chronic liver failure, erythropoietin, prediction of outcome, gastrointestinal hemorrhage, infection