Prognostic value of serum alpha-fetoprotein kinetics in liver failure on artificial liver support

Abstract

BACKGROUND

Liver failure, particularly acute-on-chronic liver failure, is associated with high mortality (50%-90%). The plasma exchange (PE) mode of the artificial liver support system has been shown to improve clinical outcomes, although its efficacy may vary depending on the regenerative capacity of the liver. Alpha-fetoprotein (AFP), an oncofetal glycoprotein, is reactivated during liver regeneration and may serve as a prognostic biomarker. Previous studies have reported significantly higher post-PE AFP levels in survivors than in non-survivors (286.5 ng/mL vs 82.3 ng/mL at day 7). However, the predictive value of baseline AFP stratification and serial AFP kinetics during PE therapy remains unestablished. This study investigated whether serial AFP measurements predict clinical outcomes in liver failure patients receiving PE.

AIM

To evaluate the predictive value of serial AFP measurements in liver failure patients receiving PE.

METHODS

This retrospective study included 194 liver failure patients with complete AFP data, excluding those with tumors, bleeding disorders, allergies, or unstable conditions. Patients were stratified by baseline AFP into low-AFP (< 100 ng/mL, n = 60), medium-AFP (100-200 ng/mL, n = 70), and high-AFP (> 200 ng/mL, n = 64) groups. AFP was measured before PE and on days 1, 10, 20, and 25.

RESULTS

Stratification by baseline AFP revealed significant gradients. The high-AFP group required fewer PE sessions than the low-AFP group (2.8 ± 1.0 vs 4.2 ± 1.5) but exhibited greater post-PE AFP elevation (75.1 ± 20.3 ng/mL vs 33.1 ± 10.2 ng/mL; P < 0.001). The high-AFP group demonstrated optimal values, including the lowest ammonia, bilirubin, alanine aminotransferase, aspartate aminotransferase, γ-glutamyl transferase, and the highest albumin and prothrombin activity (all post hoc P < 0.05 vs low-AFP). The medium-AFP group showed intermediate values except for prothrombin activity (35.2% ± 8.6%), which was significantly lower than in both other groups (P < 0.001). The high-AFP group had a reduced incidence of spontaneous bacterial peritonitis (9.4% vs 25.0%; P = 0.003), superior three-month survival (90.6% vs 56.7%; P < 0.001), and a higher post-treatment three-month receiver operating characteristic area under the curve (0.8851 vs 0.7051).

CONCLUSION

AFP dynamics correlate with regenerative capacity and clinical outcomes in liver failure. Serial AFP monitoring may enhance risk stratification and support personalized therapeutic strategies.

Keywords: Liver failure; Artificial liver support system; Plasma exchange; Alpha-fetoprotein; Liver function; Survival rate; Prognostic prediction

Core Tip: This study establishes that baseline alpha-fetoprotein (AFP) stratification (< 100 ng/mL, 100-200 ng/mL, > 200 ng/mL) in liver failure patients receiving plasma exchange-based artificial liver support systems predicts regenerative capacity and clinical outcomes. High-AFP patients (> 200 ng/mL) baseline AFP levels demonstrated improved liver function recovery, fewer complications, and required fewer treatment sessions compared to those with lower levels. Critically, three-month survival was dose-dependent, with baseline AFP > 200 ng/mL providing excellent prognostic discrimination. Serial AFP monitoring enables precision artificial liver support systems therapy by identifying patients with high endogenous regenerative potential.