Liver, Pancreas and Biliary TractClinical profile and predictors of mortality in patients of acute-on-chronic liver failure
Introduction
Severe hepatic dysfunction or liver failure could present in the setting of a previously healthy liver (acute liver failure), or as an acute deterioration of known or unknown underlying chronic liver disease (acute-on-chronic liver failure; ACLF), or as further deterioration of decompensated end-stage liver disease. A common but poorly understood clinical scenario is presentation as acute liver failure in a patient with chronic liver disease which was asymptomatic till now [1]. Acute liver failure per se is far less common than acute deterioration of a patient with previously undiagnosed chronic liver disease. O’Grady et al. had previously shown that patients with hyperacute liver failure have a better survival than those with a protracted subacute hepatic failure [2]. In fact, most of the patients belonging to the later group probably already have some underlying hepatic dysfunction [3]. It is extremely important to suspect and diagnose underlying chronic liver disease at the earliest so as to prevent progression from liver dysfunction to multiorgan failure. Furthermore, since the duration of hepatic insult is rather short, hepatocellular injury is likely to be less and timely interventions could help overcome the acute crisis [3]. Recently, ACLF has been defined as “an acute hepatic insult manifesting as jaundice and coagulopathy, complicated within 4 weeks by ascites and/or encephalopathy in a patient with previously diagnosed or undiagnosed chronic liver disease” [3].
The liver failure in ACLF could be of varying severity and depending on the duration and extent of hepatic injury, the clinical manifestations, disease course and occurrence of multi-organ failure (M-OF) develops. ACLF can have a rapidly progressive course and an urgent need for assessment and referral for liver transplantation. The importance of diagnosing impending or early organ failure cannot be over emphasized in this particular group of patients, as timely intervention can prevent or reverse the process and improve survival.
Several series of patients with acute deterioration of chronic liver disease have been recently reported [4], [5], [6], [7]. However, most of them have included patients only after one or more organ failure such as hepatorenal syndrome or hepatic encephalopathy has already set in besides severe liver failure [4], [5]. Patients belonging to such categories probably already have a far advanced liver disease and systemic dysfunction. The natural history and clinical profile of patients with ACLF of varying degrees of severity has not been well described in the literature. Moreover, many known prognostic models being used for cirrhosis of liver have been applied for the evaluation of ACLF. However, ideal prognostic model and predictors of mortality in ACLF have not been determined.
We prospectively studied the clinical profile, natural history and outcome of patients with ACLF. We also attempted to determine predictors of mortality and assessed various severity scores for mortality in these patients.
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Patients
This prospective study was carried out in the Department of Gastroenterology, GB Pant Hospital, New Delhi, India, between December 2007 and January 2009. Consecutive patients of ACLF were enrolled. The inclusion criterion was ACLF as per the APASL guidelines [3] (patients with acute hepatic insult manifesting as jaundice with bilirubin ≥5 mg/dL, coagulopathy with international normalized ratio [INR] ≥1.5 and complicated by ascites and/or encephalopathy within 4 weeks of jaundice). These patients
Patients
From December 2007 to January 2009, 113 patients presenting as ACLF were screened. Of these, 91 patients were enrolled in the study and rest 22 were excluded due to the following reasons: evidence of decompensated cirrhosis prior to the onset of acute hepatic insult (n = 12), presence of hepatocellular carcinoma (n = 4), portal vein thrombosis (n = 2) and no evidence of chronic liver disease (n = 4).
Clinical presentation (Table 1)
The median age of the patients was 36 (range 15 to 80) years with a predominance of males (n = 65 [74%]).
Discussion
This is the first prospective large carefully conducted study which describes the clinical profile, natural history and predictors of mortality in patients of ACLF. The data clearly show that ACLF is a serious condition with a high mortality rate. Approximately two-thirds of patients may die in the absence of liver transplantation. Most patients already have multi-organ failure at presentation which has a spiralling downhill course leading to mortality. Presence of hepatic encephalopathy, low
Conflict of interest
None declared.
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2021, Journal of Clinical and Experimental HepatologyCitation Excerpt :Furthermore, Kaplan-Meier survival curves (Figure 3) also showed significant differences in survival in patients with ACLF and AKI both at 28 days and 90 days (log-rank P value < 0.001) for a serum urea cut-off value of 41 mg/dl. Jindal and Sarin7 and Garg et al10 have earlier shown that SCr is a predictor of mortality in patients with ACLF at a cut-off value of 1.5 mg/dl. In our study too, we observed significant adverse impact on outcomes in patients with ACLF with elevated SCr levels.
World Gastroenterology Organisation classification and a new type-based prognostic model for hepatitis B virus-related acute-on-chronic liver failure
2021, Clinics and Research in Hepatology and GastroenterologyCitation Excerpt :Since ACLF can occur in patients with hepatitis B infection, non-alcoholic steatohepatitis, and alcohol-related CLD without cirrhosis, and patients with compensated or decompensated cirrhosis can develop ACLF after an acute insult, as suggested by WGO, ACLF can be divided into three categories including patients with CLD but no cirrhosis (type A), compensated cirrhosis (type B), and decompensated cirrhosis (type C) [5,6]. In the West, the most common etiologies of ACLF are alcoholic liver disease and hepatitis C virus infection, unlike in the East, where hepatitis B virus (HBV) infections dominate [7]. HBV infection is also the major cause of ACLF in China, accounting for more than 50% cases [8,9].