Skip to main content
Erschienen in: Wiener klinische Wochenschrift 7-8/2015

01.04.2015 | original article

Clinical profile, natural history, and predictors of mortality in patients with acute-on-chronic liver failure (ACLF)

verfasst von: Ivana Mikolasevic, MD, PhD, Sandra Milic, Mladen Radic, Lidija Orlic, Zeljka Bagic, Davor Stimac

Erschienen in: Wiener klinische Wochenschrift | Ausgabe 7-8/2015

Einloggen, um Zugang zu erhalten

Summary

Background

Acute-on-chronic liver failure (ACLF) is an increasingly recognized entity encompassing an acute deterioration of liver function in patients with cirrhosis, either secondary to superimposed liver injury or due to extrahepatic precipitating factors such as infection culminating in the end-organ dysfunction. Its main features are reversibility and high short-term mortality due to multiorgan failure (MOF). We aimed to analyze the clinical, laboratory, and etiological predictors of mortality and outcome in patients with ACLF.

Methods

We evaluated 1215 patients with chronic liver disease; 90 patients met the criteria for ACLF.

Results

The most common cause of underlying chronic liver disease was alcohol, and the most common acute insult (AI) in those patients was superadded alcoholic hepatitis. In all, 50% of all patients died within 30 days (71.1 % within the first 14 days after admission). MOF was the cause of death in 70 % of cases. On multivariate analysis, high serum potassium, serum creatinine higher than 90 µmol/L, and C-reactive protein > 30 mg/L were found to be independent baseline predictors of mortality. APACHE II (Acute Physiology and Chronic Health Evaluation II) score was the best predictor of short-term mortality (area under the curve (AUC), 0.878). MOF was a valuable predictor of mortality (AUC, 0.923); 33 of 35 patients who had MOF at admission died. Presence of positive systemic inflammatory response syndrome criteria at admission was also correlated with in-hospital mortality (AUC, 0.742).

Conclusion

ACLF is a serious condition with high short-term mortality. Because ACLF is reversible, it is necessary to identify at-risk patients as soon as possible to treat acute events in a timely manner.
Literatur
1.
Zurück zum Zitat Sarin SK, Kumar A, Almeida JA, Chawla YK, Fan ST, Garg H, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian pacific Association for the Study of the Liver (APASL). Hepatol Int. 2009;3:269–82.CrossRefPubMedCentralPubMed Sarin SK, Kumar A, Almeida JA, Chawla YK, Fan ST, Garg H, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian pacific Association for the Study of the Liver (APASL). Hepatol Int. 2009;3:269–82.CrossRefPubMedCentralPubMed
2.
Zurück zum Zitat Jalan R, Gines P, Olson JC, Mookerjee RP, Moreau R, Garcia-Tsao G, et al. Acute-on chronic liver failure. J Hepatol. 2012;57:1336–48.CrossRefPubMed Jalan R, Gines P, Olson JC, Mookerjee RP, Moreau R, Garcia-Tsao G, et al. Acute-on chronic liver failure. J Hepatol. 2012;57:1336–48.CrossRefPubMed
3.
Zurück zum Zitat Olson JC, Kamath PS. Acute-on-chronic liver failure: concept, natural history, and prognosis. Curr Opin Crit Care. 2011;17:165–9.CrossRefPubMed Olson JC, Kamath PS. Acute-on-chronic liver failure: concept, natural history, and prognosis. Curr Opin Crit Care. 2011;17:165–9.CrossRefPubMed
4.
Zurück zum Zitat Laleman W, Verbeke L, Meersseman P, Wauters J, Pelt J, Cassiman D, et al. Acute-on-chronic liver failure: current concepts on definition, pathogenesis, clinical manifestations and potential therapeutic interventions. Expert Rev Gastroenterol Hepatol. 2011;5(4):523–37.CrossRefPubMed Laleman W, Verbeke L, Meersseman P, Wauters J, Pelt J, Cassiman D, et al. Acute-on-chronic liver failure: current concepts on definition, pathogenesis, clinical manifestations and potential therapeutic interventions. Expert Rev Gastroenterol Hepatol. 2011;5(4):523–37.CrossRefPubMed
5.
6.
Zurück zum Zitat Krisper P, Stauber RE. MARS and Prometheus in acute-on-chronic liver failure: toxin elimination and outcome. Transplant Med. 2010;22:333–8. Krisper P, Stauber RE. MARS and Prometheus in acute-on-chronic liver failure: toxin elimination and outcome. Transplant Med. 2010;22:333–8.
7.
Zurück zum Zitat Mikolasević I, Radić M, Milić S, Stimac D. Acute-on-chronic liver failure (ACLF)-a new entity in hepatology? Lijec Vjesn. 2013;135:322–5.PubMed Mikolasević I, Radić M, Milić S, Stimac D. Acute-on-chronic liver failure (ACLF)-a new entity in hepatology? Lijec Vjesn. 2013;135:322–5.PubMed
8.
Zurück zum Zitat European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010;53:397–417.CrossRef European Association for the Study of the Liver. EASL clinical practice guidelines on the management of ascites, spontaneous bacterial peritonitis, and hepatorenal syndrome in cirrhosis. J Hepatol. 2010;53:397–417.CrossRef
9.
Zurück zum Zitat Cash WJ, McConville P, McDermott E, McCormick PA, Callender ME, McDougall NI. Current concepts in the assessment and treatment of hepatic encephalopathy. QJM. 2010;103:9–16.CrossRefPubMed Cash WJ, McConville P, McDermott E, McCormick PA, Callender ME, McDougall NI. Current concepts in the assessment and treatment of hepatic encephalopathy. QJM. 2010;103:9–16.CrossRefPubMed
10.
Zurück zum Zitat Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W, Practice Guidelines Committee of the American Association for the Study of Liver Diseases, Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922–38.CrossRefPubMed Garcia-Tsao G, Sanyal AJ, Grace ND, Carey W, Practice Guidelines Committee of the American Association for the Study of Liver Diseases, Practice Parameters Committee of the American College of Gastroenterology. Prevention and management of gastroesophageal varices and variceal hemorrhage in cirrhosis. Hepatology. 2007;46:922–38.CrossRefPubMed
11.
Zurück zum Zitat Tzeng WS, Wu RH, Lin CY, Chen JJ, Sheu MJ, Koay LB, et al. Prediction of mortality after emergent transjugular intrahepatic portosystemic shunt placement: use of APACHE II, Child-Pugh and MELD scores in Asian patients with refractory variceal hemorrhage. Korean J Radiol. 2009;10:481–9.CrossRefPubMedCentralPubMed Tzeng WS, Wu RH, Lin CY, Chen JJ, Sheu MJ, Koay LB, et al. Prediction of mortality after emergent transjugular intrahepatic portosystemic shunt placement: use of APACHE II, Child-Pugh and MELD scores in Asian patients with refractory variceal hemorrhage. Korean J Radiol. 2009;10:481–9.CrossRefPubMedCentralPubMed
12.
13.
Zurück zum Zitat Manka P, Bechmann LP, Tacke F, Sowa JP, Schlattjan M, Kälsch J, et al. Serum sodium based modification of the MELD does not improve prediction of outcome in acute liver failure. BMC Gastroenterol. 2013;13:58.CrossRefPubMedCentralPubMed Manka P, Bechmann LP, Tacke F, Sowa JP, Schlattjan M, Kälsch J, et al. Serum sodium based modification of the MELD does not improve prediction of outcome in acute liver failure. BMC Gastroenterol. 2013;13:58.CrossRefPubMedCentralPubMed
14.
Zurück zum Zitat Wlodzimirow KA, Eslami S, Chamuleau RAFM, Nieuwoudt M, Abu-Hanna A. Prediction of poor outcome in patients with acute liver failure—systematic review of prediction models. PLoS One. 2012;7:e50952.CrossRefPubMedCentralPubMed Wlodzimirow KA, Eslami S, Chamuleau RAFM, Nieuwoudt M, Abu-Hanna A. Prediction of poor outcome in patients with acute liver failure—systematic review of prediction models. PLoS One. 2012;7:e50952.CrossRefPubMedCentralPubMed
15.
Zurück zum Zitat Rajneesh AR, Rangan K, Thomas V. Acute on chronic liver failure. Calicut Med J. 2011;9(2):e6. Rajneesh AR, Rangan K, Thomas V. Acute on chronic liver failure. Calicut Med J. 2011;9(2):e6.
16.
Zurück zum Zitat Verbeke L, Nevens F, Laleman W. Bench-to-beside review: acute-on-chronic liver failure—linking the gut, liver and systemic circulation. Crit Care. 2011;15:233.CrossRefPubMedCentralPubMed Verbeke L, Nevens F, Laleman W. Bench-to-beside review: acute-on-chronic liver failure—linking the gut, liver and systemic circulation. Crit Care. 2011;15:233.CrossRefPubMedCentralPubMed
17.
Zurück zum Zitat Garg H, Kumar A, Garg V, Sharma P, Sharma BC, Sarin SK. Clinical profile and predictors of mortality in patients of acute-on-chronic liver failure. Dig Liver Dis. 2012;44:166–71.CrossRefPubMed Garg H, Kumar A, Garg V, Sharma P, Sharma BC, Sarin SK. Clinical profile and predictors of mortality in patients of acute-on-chronic liver failure. Dig Liver Dis. 2012;44:166–71.CrossRefPubMed
18.
Zurück zum Zitat Cárdenas A, Ginès P. Acute-on-chronic liver failure: the kidneys. Curr Opin Crit Care. 2011;17:184–9.CrossRefPubMed Cárdenas A, Ginès P. Acute-on-chronic liver failure: the kidneys. Curr Opin Crit Care. 2011;17:184–9.CrossRefPubMed
19.
Zurück zum Zitat Gentilini P, Vizzutti F, Gentilini A, La Villa G. Ascites and hepatorenal syndrome. Eur J Gastroenterol Hepatol. 2001;13:313–6.CrossRefPubMed Gentilini P, Vizzutti F, Gentilini A, La Villa G. Ascites and hepatorenal syndrome. Eur J Gastroenterol Hepatol. 2001;13:313–6.CrossRefPubMed
20.
Zurück zum Zitat Olson JC, Kamath PS. Acute-on-chronic liver failure: what are the implications. Curr Gastroenterol Rep. 2012;14:63–6.CrossRefPubMed Olson JC, Kamath PS. Acute-on-chronic liver failure: what are the implications. Curr Gastroenterol Rep. 2012;14:63–6.CrossRefPubMed
21.
Zurück zum Zitat Huang K, Hu JH, Wang HF, He WP, Chen J, Duan XZ, et al. Survival and prognostic factors in hepatitis B virus-related acute-on-chronic liver failure. World J Gastroenterol. 2011;17(29):3448–52.CrossRefPubMedCentralPubMed Huang K, Hu JH, Wang HF, He WP, Chen J, Duan XZ, et al. Survival and prognostic factors in hepatitis B virus-related acute-on-chronic liver failure. World J Gastroenterol. 2011;17(29):3448–52.CrossRefPubMedCentralPubMed
22.
Zurück zum Zitat Moreau R, Jalan R, Gines P, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144:1426–37.CrossRefPubMed Moreau R, Jalan R, Gines P, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144:1426–37.CrossRefPubMed
23.
Zurück zum Zitat Jalan R. Stadlbauer V, Sen S, et al. Natural history of acute decompensation of cirrhosis: the basis of the definition, prognosis, and pathophysiology of acute-on-chronic liver failure. Hepatology. 2006;44(Suppl. 1):371A–2A. Jalan R. Stadlbauer V, Sen S, et al. Natural history of acute decompensation of cirrhosis: the basis of the definition, prognosis, and pathophysiology of acute-on-chronic liver failure. Hepatology. 2006;44(Suppl. 1):371A–2A.
24.
Zurück zum Zitat Freire P, Romãozinho JM, Amaro P, Ferreira M, Sofia C. Prognostic scores in cirrhotic patients admitted to a gastroenterology intensive care unit. Rev Esp Enferm Dig. 2011;103(4):177–83.CrossRefPubMed Freire P, Romãozinho JM, Amaro P, Ferreira M, Sofia C. Prognostic scores in cirrhotic patients admitted to a gastroenterology intensive care unit. Rev Esp Enferm Dig. 2011;103(4):177–83.CrossRefPubMed
25.
Zurück zum Zitat Wehler M, Kokoska J, Reulbach U, Hahn EG, Strauss R. Short-term prognosis in critically ill patients with cirrhosis assessed by prognostic scoring systems. Hepatology. 2001;34:255–61.CrossRefPubMed Wehler M, Kokoska J, Reulbach U, Hahn EG, Strauss R. Short-term prognosis in critically ill patients with cirrhosis assessed by prognostic scoring systems. Hepatology. 2001;34:255–61.CrossRefPubMed
26.
27.
Zurück zum Zitat Yu JW, Wang GQ, Li SC. Prediction of the prognosis in patients with acute-on-chronic hepatitis using the MELD scoring system. J Gastroenterol Hepatol. 2006;21:1519–24.CrossRefPubMed Yu JW, Wang GQ, Li SC. Prediction of the prognosis in patients with acute-on-chronic hepatitis using the MELD scoring system. J Gastroenterol Hepatol. 2006;21:1519–24.CrossRefPubMed
28.
Zurück zum Zitat Hessel FP, Bramlage P, Wasem J, Mitzner SR. Cost-effectiveness of the artificial liver support system MARS in patients with acute-on-chronic liver failure. Eur J Gastroenterol Hepatol. 2010;22:213–20.CrossRefPubMed Hessel FP, Bramlage P, Wasem J, Mitzner SR. Cost-effectiveness of the artificial liver support system MARS in patients with acute-on-chronic liver failure. Eur J Gastroenterol Hepatol. 2010;22:213–20.CrossRefPubMed
29.
Zurück zum Zitat Bajaj JS. Defining acute-on-chronic liver failure: will East and West ever meet? Gastroenterology. 2013;144:1337–9.CrossRefPubMed Bajaj JS. Defining acute-on-chronic liver failure: will East and West ever meet? Gastroenterology. 2013;144:1337–9.CrossRefPubMed
30.
Zurück zum Zitat Moreau R, Jalan R, Gines P, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144:1426–37.CrossRefPubMed Moreau R, Jalan R, Gines P, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144:1426–37.CrossRefPubMed
Metadaten
Titel
Clinical profile, natural history, and predictors of mortality in patients with acute-on-chronic liver failure (ACLF)
verfasst von
Ivana Mikolasevic, MD, PhD
Sandra Milic
Mladen Radic
Lidija Orlic
Zeljka Bagic
Davor Stimac
Publikationsdatum
01.04.2015
Verlag
Springer Vienna
Erschienen in
Wiener klinische Wochenschrift / Ausgabe 7-8/2015
Print ISSN: 0043-5325
Elektronische ISSN: 1613-7671
DOI
https://doi.org/10.1007/s00508-015-0707-9

Weitere Artikel der Ausgabe 7-8/2015

Wiener klinische Wochenschrift 7-8/2015 Zur Ausgabe

MUW researcher of the month

Researcher of the month

MUW researcher of the month

Researcher of the month

mitteilungen der gesellschaft

ÖGIM FLIP