Acute-on-chronic liver failure: Definitions, pathophysiology and principles of treatment

Alcohol and Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is a clinical syndrome that occurs in patients with cirrhosis and is characterised by acute deterioration, organ failure and high short-term mortality. Alcohol is one of the leading causes of ACLF and the most frequently reported aetiology of underlying chronic liver disease. Among patients with alcoholic hepatitis (AH), ACLF is a frequent and severe complication. It is characterised by both immune dysfunction associated to an increased risk of infection and high-grade systemic inflammation that ultimately induce organ failure. Diagnosis and severity of ACLF determine AH prognosis, and therefore, ACLF prognostic scores should be used in severe AH with organ failure. Corticosteroids remain the first-line treatment for severe AH but they seem insufficient when ACLF is associated. Novel therapeutic targets to contain the excessive inflammatory response and reduce infection have been identified and are under investigation. With liver transplantation remaining one of the most effective therapies for severe AH and ACLF, adequate organ allocation represents a growing challenge. Hence, a clear understanding of the pathophysiology, clinical implications and management strategies of ACLF in AH is essential for hepatologists, which is narrated briefly in this review.

Distinct responses between healthy and cirrhotic human livers upon lipopolysaccharide challenge: possible implications for acute-on-chronic liver failure

Patients with acute-on-chronic liver failure (ACLF) are at risk of developing acute hepatic decompensation and organ failures with an unraveled complex mechanism. An altered immune response toward insults in cirrhotic compared with healthy livers may contribute to the ACLF development. Therefore, we aim to investigate the differences in inflammatory responses between cirrhotic and healthy livers using human precision-cut liver slices (PCLSs) upon the lipopolysaccharide (LPS) challenge. PCLSs prepared from livers of patients with cirrhosis or healthy donors of liver transplantation were incubated ex vivo with or without LPS for up to 48 h. Viability test, qRT-PCR, and multiplex cytokine assay were performed. Regulation of the LPS receptors during incubation or with LPS challenge differed between healthy versus cirrhotic PCLSs. LPS upregulated TLR-2 in healthy PCLSs solely (P < 0.01). Culturing for 48 h induced a stronger inflammatory response in the cirrhotic than healthy PCLS. Upon LPS stimulation, cirrhotic PCLSs secreted more proinflammatory cytokines (IL-8, IL-6, TNF-α, eotaxin, and VEGF) significantly and less anti-inflammatory cytokine (IL-1ra) than those of healthy. In summary, cirrhotic PCLSs released more proinflammatory and less anti-inflammatory cytokines after LPS stimuli than healthy, leading to dysregulated inflammatory response. These events could possibly resemble the liver immune response in ACLF.NEW & NOTEWORTHY Precision-cut liver slices (PCLSs) model provides a unique platform to investigate the different immune responses of healthy versus cirrhotic livers in humans. Our data show that cirrhotic PCLSs exhibit excessive inflammatory response accompanied by a lower anti-inflammatory cytokine release in response to LPS; a better understanding of this alteration may guide the novel therapeutic approaches to mitigate the excessive inflammation during the onset of acute-on-chronic liver failure.

The Immune Pathogenesis of Acute-On-Chronic Liver Failure and the Danger Hypothesis

Acute-on-chronic liver failure (ACLF) is a group of clinical syndromes related to severe acute liver function impairment and multiple-organ failure caused by various acute triggering factors on the basis of chronic liver disease. Due to its severe condition, rapid progression, and high mortality, it has received increasing attention. Recent studies have shown that the pathogenesis of ACLF mainly includes direct injury and immune injury. In immune injury, cytotoxic T lymphocytes (CTLs), dendritic cells (DCs), and CD4⁺ T cells accumulate in the liver tissue, secrete a variety of proinflammatory cytokines and chemokines, and recruit more immune cells to the liver, resulting in immune damage to the liver tissue, massive hepatocyte necrosis, and liver failure, but the key molecules and signaling pathways remain unclear. The “danger hypothesis” holds that in addition to the need for antigens, damage-associated molecular patterns (DAMPs) also play a very important role in the occurrence of the immune response, and this hypothesis is related to the pathogenesis of ACLF. Here, the research status and development trend of ACLF, as well as the mechanism of action and research progress on various DAMPs in ACLF, are summarized to identify biomarkers that can predict the occurrence and development of diseases or the prognosis of patients at an early stage.

Improvement Effect of PERMA Model-Based Nursing Intervention plus Music Therapy on Patients with Acute Liver Failure Undergoing Plasma Exchange Therapy

Objective

To explore the improvement effect of PERMA model-based nursing intervention plus music therapy (MT) on patients with acute liver failure (AHF) undergoing plasma exchange therapy (PET).

Methods

This research included 100 AHF patients treated with PET in our hospital, between January 2020 and December 2021, including 54 cases receiving PERMA model-based nursing intervention plus MT (observation group, OG) and 46 cases receiving routine nursing (control group, CG). Clinical efficacy and liver function (LF) were compared between the groups. Prenursing and postnursing psychology, treatment compliance, sleep, pain, and quality of life were assessed, and patient satisfaction was investigated at discharge.

Results

The postnursing overall efficacy showed no evident difference between the groups (P > 0.05). The clinical efficacy was mainly markedly significant (50.00%) in OG and effective (43.48%) in CG. The overall response rate was not statistically different between groups (χ 2 = 1.392, P > 0.05). OG presented better LF, treatment compliance, and sleep quality after nursing, with milder negative emotions and pain than CG (P < 0.05). A higher patient satisfaction rate was also determined in OG at discharge (P < 0.05).

Conclusions

PERMA model-based nursing intervention plus MT can effectively improve the psychological state, treatment compliance, and quality of life of AHF patients with PET and reduce pain sensation, which has promising clinical application value in the future.

Discordance in categorization of acute-on-chronic liver failure in the United Network for Organ Sharing database

BACKGROUND & AIMS

Studies regarding acute-on-chronic liver failure (ACLF) among liver transplant (LT) candidates from the United Network for Organ Sharing (UNOS) database are being used to inform LT policy changes worldwide. We assessed the validity of identifying ACLF in UNOS.

METHODS

We performed stratified random sampling among 3 US LT centers between 2013-2019 to obtain a representative patient sample across ACLF grades. We compared the concordance of ACLF classification by UNOS vs. blinded manual chart review, according to EASL-CLIF.

RESULTS

Among 481 sampled LT registrants, 250 (52%) had no ACLF, 75 (16%) had ACLF grade 1, 79 (16%) had ACLF grade 2, and 77 (16%) had ACLF grade 3 per UNOS categorization. Concordance of ACLF grade by UNOS vs. chart review was: 72%, 64%, 56%, and 64% for no ACLF, grade 1, grade 2, and grade 3, respectively, with an overall Cohen's kappa coefficient of 0.48 (95% CI 0.42-0.54). Absence of acute decompensation was the most common reason for overestimation, and discordant brain and respiratory failure categorization were the most common reasons for underestimation of ACLF by UNOS.

CONCLUSIONS

In this retrospective multi-center study, ACLF categorization by UNOS showed weak agreement with manual chart review. These findings are informative for ongoing allocation policy discussions, highlight the importance of prospective studies regarding ACLF in LT, and should encourage UNOS reform.

LAY SUMMARY

Acute-on-chronic-liver-failure (ACLF) is a specific and common form of liver failure associated with high death rates. Studies have been published using the United States transplant registry (UNOS) to identify and describe outcomes of transplant candidates and recipients with ACLF, and these data are driving policy changes for transplant allocation around the world, but nobody has shown whether these data are reliable. We found that UNOS was not categorizing ACLF in concordance or accurately when compared to chart review, which shows the need for UNOS reform and non-UNOS studies to appropriately inform policies regarding the transplantation of patients with ACLF.

Serum 25-hydroxyvitamin D and C-reactive protein and plasma von Willebrand concentrations in 23 dogs with chronic hepatopathies

BACKGROUND

Serum concentrations of 25-hydroxyvitamin D (25(OH)VD) and C-reactive protein (CRP) and von Willebrand's factor (vWF) concentration correlate with histopathologic disease grade and stage in chronic inflammatory and fibrotic hepatopathies (CH) in humans.

OBJECTIVES

To evaluate serum 25(OH)VD and serum CRP concentrations and plasma vWF concentration and determine if they correlate with histopathologic and biochemical variables in dog with CH.

ANIMALS

Twenty-three client-owned dogs with a histopathologic diagnosis of CH were prospectively enrolled.

METHODS

Blood samples were collected before liver biopsy. Correlations between biomarkers and clinical pathological and histopathologic variables were evaluated using Pearson's or Spearman's test.

RESULTS

Serum 25(OH)VD concentration (median, 213 nmol/L; range, 42-527 nmol/L) was negatively correlated with serum aspartate aminotransferase activity (AST; rho = -0.59, P < .01), polymorphonuclear neutrophil count (PMN; r = -0.46, P < .05), and positively correlated with serum albumin concentration (r = 0.69, P < .001). Serum CRP concentration (median, 7.4 μg/L; range, 1-44.9 μg/L) was positively correlated with overall histopathologic necroinflammatory activity (r = 0.78, P < .001) and fibrosis score (rho = 0.49, P < .05). Plasma vWF concentration (median, 73.3%; range, 15-141%) was positively correlated with fibrosis score (r = 0.53, P < .05) and prothrombin time (rho = 0.67, P < .01), and negatively correlated with serum albumin concentration (r = -0.73, P < .001).

CONCLUSION AND CLINICAL IMPORTANCE

In dogs with CH, serum 25(OH)VD concentration was negatively correlated with disease activity, whereas serum CRP concentration and plasma vWF concentration were positively correlated with histopathologic grade and stage. Our results provide preliminary evidence that these biomarkers may be useful to assess grade and stage of CH in dogs in the absence of liver biopsy.

Wenyang Huazhuo Tuihuang Formula Inhibits the Th17/Treg Cell Imbalance and Protects against Acute-on-Chronic Liver Failure

Objective

Acute-on-chronic liver failure (ACLF) is a group of chronic liver diseases and caused by acute internal and external liver injury. Wenyang Huazhuo Tuihuang (WYHZTH) formula had a good clinical effect on promoting the resolution of jaundice. The aim of this study is to further investigate the mechanism of the WYHZTH formula in the ACLF rat model.

Methods

The ACLF rat model was constructed by combining human serum albumin with LPS and D-gal. WYHZTH was used to intervene and treat. The cytokines IL-17, IL-23, IL-10, and TGF-β were detected by ELISA and fluorescence-quantitative PCR. Flow cytometry was used to detect the percentage of Th17 and Treg cells in the peripheral blood and liver tissues of each group of rats. The pathological changes in the liver tissue were detected by hematoxylin-eosin staining, immunohistochemistry, and electron microscopy.

Results

Compared with the ACLF group, the WYHZTH formula and Thy significantly decreased the levels of ALT, AST, and CHE in the ACLF group. After drug intervention, apoptosis was significantly reduced. The PCNA expression decreased in the ACLF model group but increased in the WYHZTH or Thy group. Under transmission electron microscope, hepatocytes in the ACLF group showed obvious necrosis. After drug intervention, hepatocyte necrosis was reduced with most of the structure returning to normal.

Conclusion

This present study demonstrated that WYHZTH formula may protect against acute-on-chronic liver failure, which may be related to the inhibition of Th17/Treg cell imbalance.

Re-evaluation of King Wilson Index in Children With Acutely Decompensated Hepatic Wilson Disease

OBJECTIVES

Liver transplantation (LT) in Wilson disease (WD) is a life-saving option for patients presenting with liver failure and encephalopathy. Patients without encephalopathy can avoid LT and treated successfully with chelation therapy. It is essential to predict the risk of fatal outcomes where LT is required. We aim to critically analyse the validity of the WD Index prospectively from a cohort of WD patients managed at our institution.

METHODS

WD Index and other clinical data from 2005 to 2018, recorded prospectively as part of clinical management, were analysed.

RESULTS

Over 13-year period, 52 children with WD (29 boys) with median age at diagnosis of 11.69 (range 3.92-17.26) years were studied. Of these, 17 were diagnosed as part of family screening, 17 presented with abnormal liver enzyme, and 18 with acute hepatic decompensation (AHD) as per PALF definition. Patients presented with abnormal liver enzyme and in the pre-symptomatic group had WD Index <11, and none of them required LT. WD Index is still a good predictor for LT in WD patients with AHD, providing a sensitivity of 80%, specificity of 100%, positive-predictive, and negative-predictive value of 100% and 80%, respectively. Patients presented with an index of 8-10 also required LT at median duration of 58 days (IQR 48-135 days).

CONCLUSIONS

WD patients presenting with AHD who had an index of ≥11 do require LT. Children with a WD Index of 8 to 10 within the first 2 months of admission require close monitoring as LT may become necessary.

Molecular characterization of chronic liver disease dynamics: from liver fibrosis to acute-on-chronic liver failure

Background & Aims

The molecular mechanisms driving the progression from early-chronic liver disease (CLD) to cirrhosis and, finally, acute-on-chronic liver failure (ACLF) are largely unknown. Our aim was to develop a protein network-based approach to investigate molecular pathways driving progression from early-CLD to ACLF.

Methods

Transcriptome analysis was performed on liver biopsies from patients at different liver disease stages, including fibrosis, compensated cirrhosis, decompensated cirrhosis and ACLF, and control healthy livers. We created 9 liver-specific disease-related protein-protein interaction networks capturing key pathophysiological processes potentially related to CLD. We used these networks as a framework and performed gene set-enrichment analysis (GSEA) to identify dynamic gene profiles of disease progression.

Results

Principal component analyses revealed that samples clustered according to the disease stage. GSEA of the defined processes showed an upregulation of inflammation, fibrosis and apoptosis networks throughout disease progression. Interestingly, we did not find significant gene expression differences between compensated and decompensated cirrhosis, while ACLF showed acute expression changes in all the defined liver disease-related networks. The analyses of disease progression patterns identified ascending and descending expression profiles associated with ACLF onset. Functional analyses showed that ascending profiles were associated with inflammation, fibrosis, apoptosis, senescence and carcinogenesis networks, while descending profiles were mainly related to oxidative stress and genetic factors. We confirmed by qPCR the upregulation of genes of the ascending profile and validated our findings in an independent patient cohort.

Conclusion

ACLF is characterized by a specific hepatic gene expression pattern related to inflammation, fibrosis, apoptosis, senescence and carcinogenesis. Moreover, the observed profile is significantly different from that of compensated and decompensated cirrhosis, supporting the hypothesis that ACLF should be considered a distinct entity.

Lay summary

By using transjugular biopsies obtained from patients at different stages of chronic liver disease, we unveil the molecular pathogenic mechanisms implicated in the progression of chronic liver disease to cirrhosis and acute-on-chronic liver failure. The most relevant finding in this study is that patients with acute-on-chronic liver failure present a specific hepatic gene expression pattern distinct from that of patients at earlier disease stages. This gene expression pattern is mostly related to inflammation, fibrosis, angiogenesis, and senescence and apoptosis pathways in the liver.

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We unveiled the molecular pathogenic mechanisms implicated in the progression of chronic liver disease to cirrhosis and ACLF.

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ACLF presents a specific hepatic gene expression pattern distinct from that of patients at earlier disease stages.

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Gene expression pattern of ACLF is mostly related to inflammation, fibrosis, angiogenesis, senescence and apoptosis pathways in the liver.

Liver Transplantation as a Cornerstone Treatment for Acute-On-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is a distinct clinical syndrome, characterized by acute decompensation (AD) of liver cirrhosis, severe systemic inflammation, intra- and extrahepatic organ failures, and a high short-term mortality. Liver transplantation (LT) is a potentially life-saving treatment for patients with decompensated liver cirrhosis and, due to the high mortality rates, particularly for ACLF patients. In the last decade, a plethora of studies has produced compelling evidence in favor of LT in ACLF, demonstrating high post-LT survival rates and excessive waitlist mortality. The importance of LT in these patients is underscored by the fact that no specific therapy for ACLF is available yet, rendering expeditious life-saving LT to be the only feasible treatment option for some ACLF patients. This review aims to provide an overview on pathophysiology, clinical trajectory, and clinical management of ACLF and to delineate the current literature regarding perspectives and limitations of LT as a life-saving treatment option for ACLF patients.

Acute‐on‐chronic liver failure: Epidemiology, prognosis, and outcome of a multicenter study in Thai population

Background and Aim

Acute‐on‐chronic liver failure (ACLF) leads to multi‐organ failure related to high mortality rates. This study aimed to gather epidemiological data and validate a scoring system to predict mortality in ACLF.

Methods

This retrospective cohort study collected data from multicenter tertiary care hospitals in Thailand. A total of 638 hospitalized patients (acute decompensated liver disease [ADLD], 292 patients; ACLF, 346 patients) from January 2019 to June 2020 were enrolled in this study. We compared the mortality rate at days 30 and 90 between patients with ADLD and ACLF. Areas under the receiver operating characteristic (AUROC) curves of chronic liver failure–sequential organ failure assessment (CLIF‐SOFA) and other existing scoring systems were compared among patients with ACLF.

Results

The incidence of patients with ACLF was 54%. The main cause of chronic liver disease was alcohol (38%), with sepsis (50%) as the most common precipitating factor. ACLF with coagulopathy (AUROC 0.58, 95% confidence interval [CI]: 0.52–0.64), metabolic acidosis (AUROC 0.58, 95% CI: 0.52–0.64), and high aspartate aminotransferase (AST) (AUROC 0.59, 95% CI: 0.53–0.66) were associated with high 30‐day mortality. The 30‐day mortality rate of patients with acute decompensation and patients with ACLF was 46 and 58%, respectively. Respiratory system (P = 0.001) failure was the major end result in ACLF and constituted a significant factor to predict mortality. The AUROC of CLIF‐SOFA score was superior to that of the other predicted score (AUROC 0.64, 95% CI: 0.585–0.704).

Conclusion

Patients with ACLF with more organ failure and high CLIF‐SOFA score were associated with high short‐term mortality. Future studies should include an ACLF prospective registry to confirm these finding.

Low Volume Plasma Exchange and Low Dose Steroid Improve Survival in Patients With Alcohol-Related Acute on Chronic Liver Failure and Severe Alcoholic Hepatitis - Preliminary Experience

Background

Alcohol-related acute on chronic liver failure (A-ACLF) patients have high short-term mortality and are poor candidates for steroid therapy. Plasma exchange (PLEX) improves survival in ACLF patients. We analyzed our experience with low volume PLEX (50% of plasma volume exchanged per session) and low dose steroids to treat A-ACLF patients.

Methods

We retrospectively compared the efficacy of low volume PLEX and low-dose steroids with standard medical treatment (SMT) in A-ACLF patients treated at our center between November 2017 to June 2019. The primary study outcome was one-year survival.

Results

Twenty-one A-ACLF patients in PLEX group [age 40 (29-56) years, median (range); MELD score 31 (29-46)] and 29 A-ACLF patients in SMT group [age 41.5 (28-63) years, MELD score 37 (21-48)] were studied. All 50 study patients had severe alcoholic hepatitis [mDF 84.7 (50-389)]. PLEX group patients had 3 (1-7) PLEX sessions with 1.5 (1.4-1.6) liters of plasma exchanged per session and oral Prednisolone 20 mg daily, tapered over 1 month. Kaplan Meier analysis showed better survival over 1 year in the PLEX group compared to the SMT group (P = 0.03). There was renal dysfunction in 10 patients in the PLEX group, which normalized in six patients after PLEX.

Conclusion

In this preliminary report, compared to SMT, low volume PLEX and low dose steroid improved survival over one year in A-ACLF patients with severe alcoholic hepatitis. In patients with renal dysfunction, 60% showed improvement in renal function with PLEX. Studies with a larger number of patients are needed to validate these results.

Modified EASL-CLIF criteria that is easier to use and perform better to prognosticate acute-on-chronic liver failure

BACKGROUND

We have recently shown that the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria showed a better sensitivity to detect acute-on-chronic liver failure (ACLF) with a better prognostic capability than the North American Consortium for the Study of End-Stage Liver Disease criteria.

AIM

To simplify EASL-CLIF criteria for ease of use without sacrificing its sensitivity and prognostic capability.

METHODS

Using the United Network for Organ Sharing data (January 11, 2016, to August 31, 2020), we modified EASL-CLIF (mEACLF) criteria; the modified mEACLF criteria included six organ failures (OF) as in the original EASL-CLIF, but renal failure was defined as creatinine ≥ 2.35 mg/dL and coagulation failure was defined as international normalized ratio (INR) ≥ 2.0. The mEACLF grades (0, 1, 2, and ≥ 3) directly reflected the number of OF.

RESULTS

Of the 40357 patients, 14044 had one or more OF, and 9644 had ACLF grades 1-3 by EASL-CLIF criteria. By the mEACLF criteria, 15574 patients had one or more OF. The area under the receiver operating characteristic (AUROC) for 30-d all-cause mortality by OF was 0.842 (95%CI: 0.831-0.853) for mEACLF and 0.835 (95%CI: 0.824-0.846) for EASL-CLIF (P = 0.006), and AUROC for 30-d transplant-free mortality by OF was 0.859 (95%CI: 0.849-0.869) for mEACLF and 0.851 (95%CI: 0.840-0.861) for EASL-CLIF (P = 0.001). The AUROC of 30-d all-cause mortality by ACLF grades was 0.842 (95%CI: 0.831-0.853) for mEACLF and 0.793 (95%CI: 0.781-0.806) for EASL-CLIF (P < 0.0001). The AUROC of 30-d transplant-free mortality by ACLF was 0.859 (95%CI: 0.848-0.869) for mEACLF and 0.805 (95%CI: 0.793-0.817) for EASL-CLIF (P < 0.0001).

CONCLUSION

Our study showed that EASL-CLIF criteria for ACLF grades could be simplified for ease of use without losing its prognostication capability and sensitivity.

Wilson disease in children and young adults - State of the art

Wilson disease (WD) is an autosomal recessive disorder caused by mutations of the ATP7B gene, with a reported prevalence of 1:30,000-50,000. ATP7B encodes an enzyme called transmembrane copper-transporting ATPase, which is essential for copper incorporation into ceruloplasmin and for copper excretion into the bile. A lack or dysfunction of this enzyme results in a progressive accumulation of copper in several organs, especially in the liver, the nervous system, corneas, kidneys, and heart. Children with WD can present with asymptomatic liver disease, cirrhosis, or acute liver failure, with or without neurological and psychiatric symptoms. Approximately 20%-30% of WD patients present with ALF, while most of the other patients have chronic progressive hepatitis or cirrhosis if untreated. Although genetic testing has become a more important diagnostic tool for WD, the diagnosis remains based on both clinical features and laboratory investigations. The aims of treatment are to reduce copper levels and prevent its accumulation in the liver and other organs, especially in the central nervous system. Liver transplantation in WD is a life-saving option for patients presenting with liver failure and encephalopathy. For WD patients treated with chelating agents, adherence to the therapy is essential for long-term success. In this review, we also address specific issues in young adults as compared to children.

Liver Biopsy in Patients With Alcohol-Associated Liver Disease With Acute-on-Chronic Liver Failure

Patients with alcohol-associated liver disease may develop severe forms of presentation of acute-on-chronic liver failure, with a high risk for short-term mortality. Alcoholic hepatitis should be suspected among patients with alcohol-associated liver disease who present with acute-on-chronic liver failure. In this review, we discuss the need and feasibility of liver biopsy in the diagnosis of alcoholic hepatitis and predicting its prognosis among decompensated patients with alcohol-associated liver disease and acute-on-chronic liver failure.

Increased INR Values Predict Accelerating Deterioration and High Short-Term Mortality Among Patients Hospitalized With Cirrhosis or Advanced Fibrosis

Background and Objective: An increase in the international normalized ratio (INR) is associated with increased mortality in patients with cirrhosis and other chronic liver diseases, while little is known about the quantitative relationship. This study aimed to investigate the quantitative relationship between the INR and short-term prognosis among patients hospitalized with cirrhosis or advanced fibrosis and to evaluate the role of the INR as a risk factor for short-term liver transplant (LT)-free mortality in these patients.

Patients and Methods: This study prospectively analyzed multicenter cohorts established by the Chinese Acute-on-Chronic Liver Failure (CATCH-LIFE) study. Cox regression was used to describe the relationship between the INR and independent risk factors for short-term LT-free mortality. Forest plots were used in the subgroup analysis. Generalized additive models (GAMs) and splines were used to illustrate the quantitative curve relationship between the INR and the outcome and inflection point on the curve.

Results: A total of 2,567 patients with cirrhosis and 924 patients with advanced fibrosis were included in the study. The 90-day LT-free mortality of patients with cirrhosis and advanced fibrosis was 16.7% (428/2,567) and 7.5% (69/924), respectively. In the multivariable Cox regression analysis, the increase in the INR was independently associated with the risk of 90-day LT-free mortality both in patients with cirrhosis (HR, 1.06; 95% CI, 1.04–1.07, p < 0.001) and in patients with advanced fibrosis (HR, 1.09; 95% CI, 1.06–1.12, p < 0.001). An INR of 1.6/1.7 was found to be the starting point of coagulation dysfunction with a rapid increase in mortality in patients with cirrhosis or in patients with advanced fibrosis, respectively. A 28-day LT-free mortality of 15% was associated with an INR value of 2.1 in both cirrhosis and advanced fibrosis patients.

Conclusions: This study was the first to quantitatively describe the relationship between the INR and short-term LT-free mortality in patients with cirrhosis or advanced fibrosis. The starting points of INR indicating the rapid increase in mortality and the unified cutoff value of coagulation failure in cirrhosis and advanced fibrosis, will help clinicians accurately recognize early disease deterioration.

Transcriptomics reveals immune-metabolism disorder in acute-on-chronic liver failure in rats

Liver tissue transcriptomics of liver cirrhosis (LC)–based acute-on-chronic liver failure (ACLF) rats reveal immune-metabolism disorder as the core mechanism underlying ACLF development and prognosis.

Acute-on-chronic liver failure (ACLF) is clinical syndrome with high mortality rate. This study aimed to perform detailed transcriptomic analysis in liver cirrhosis–based ACLF rats to elucidate ACLF pathogenesis. ACLF was induced by combined porcine serum with D-galactosamine and lipopolysaccharide. Gene expression profile of liver tissues from ACLF rats was generated by transcriptome sequencing to reveal the molecular mechanism. ACLF rats successfully developed with typical characteristics. Total of 2,354/3,576 differentially expressed genes were identified when ACLF was compared to liver cirrhosis and normal control, separately. The functional synergy analysis revealed prominent immune dysregulation at ACLF stage, whereas metabolic disruption was significantly down-regulated. Relative proportions of innate immune–related cells showed significant elevation of monocytes and macrophages, whereas adaptive immune–related cells were reduced. The seven differentially expressed genes underlying the ACLF molecular mechanisms were externally validated, among them THBS1, IL-10, and NR4A3 expressions were confirmed in rats, patient transcriptomics, and liver biopsies, verifying their potential value in the ACLF pathogenesis. This study indicates immune-metabolism disorder in ACLF rats, which may provide clinicians new targets for improving intervention strategies.

Acute-on-Chronic Liver Failure: Pathophysiological Mechanisms and Management

Acute-on-chronic liver failure (ACLF) is a multifaceted condition with poor treatment options and high short-term mortality. ACLF can develop in patients with or without liver cirrhosis, where patients with decompensated cirrhosis display a higher risk of short-term mortality. Pathophysiological mechanisms include systemic inflammation due to bacterial and fungal infections and acute hepatic insult with drug, alcohol, and viral hepatitis. Cryptogenic factors also contribute to the development of ACLF. The clinical outcome of patients with ACLF gets further complicated by the occurrence of variceal hemorrhage, hepatorenal syndrome, hepatic encephalopathy, and systemic immune dysfunction. Regardless of the better understanding of pathophysiological mechanisms, no specific and definitive treatment is available except for liver transplantation. The recent approach of regenerative medicine using mesenchymal stem cells (MSCs) could be advantageous for the treatment of ACLF as these cells can downregulate inflammatory response by inducing antiinflammatory events and prevent hepatic damage and fibrosis by inhibiting hepatic stellate cell activation and collagen synthesis. Moreover, MSCs are involved in tissue repair by the process of liver regeneration. Considering the broad therapeutic potential of MSCs, it can serve as an alternative treatment to liver transplant in the near future, if promising results are achieved.

Plasma Exchange in Acute and Acute on Chronic Liver Failure

Liver failure in the context of acute (ALF) and acute on chronic liver failure (ACLF) is associated with high mortality in the absence of a liver transplant. For decades, therapeutic plasma exchange (TPE) is performed for the management of immune-mediated diseases. TPE has emerged as an attractive extracorporeal blood purification technique in patients with ALF and ACLF. The basic premise of using TPE is to remove the toxic substances which would allow recovery of native liver functions by facilitating liver regeneration. In recent years, encouraging data have emerged, suggesting the benefits of TPE in patients with liver failure. TPE has emerged as an attractive liver support device for the failing liver until liver transplantation or clinical recovery. The data in patients with ALF suggest routine use of high-volume TPE, while the data for such a strategy are less robust for patients with ACLF.

EASL-CLIF criteria outperform NACSELD criteria for diagnosis and prognostication in ACLF

BACKGROUND & AIMS

There is no consensus on the best definition for acute-on-chronic liver failure (ACLF). In this study, we compared the prevalence and 30-day all-cause and transplant-free mortality of patients with ACLF identified by European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) and North American Consortium for the Study of End-stage Liver Disease (NACSELD) criteria.

METHODS

We performed this comparative analysis using the United Network for Organ Sharing (UNOS) data from January 11, 2016 to August 31, 2020.

RESULTS

A total of 10,198 (21%) adult patients had EASL-CLIF ACLF grade 1-3, but of these only 15.3% had ACLF by NACSELD. Of the 2,562 with EASL-CLIF ACLF grade 3, only 48.8% had NACSELD-ACLF, 16.8% had no organ failure (OF) and 34.4% had 1 OF. The 30-day all-cause mortality was 1.5%, 7.7%, 13.3% and 25.8% for EASL-CLIF grade 0-3, respectively, and it was 15.4% and 28.1% in those without and with NACSELD-ACLF. When EASL-CLIF grade 3 patients were stratified by NACSELD OF, the mortality ranged from 18.6% with no OF to 41.0% with 4 OFs. The 30-day transplant-free mortality in those with no OF by NACSELD was 2.7%, but when the same group is stratified by EASL-CLIF grades 0-3, the mortality rates were 1.5%, 10.5%, 43.5% and 86%, respectively; the mortality rates ranged from 3.0% to 75.7% in those with 1 OF by NACSELD.

CONCLUSIONS

There is a clear discordance in the prevalence and 30-day mortality rates of patients with ACLF identified by the EASL-CLIF and NACSELD criteria. EASL-CLIF criteria have a better sensitivity to detect ACLF and have a better prognostic capability.

LAY SUMMARY

There is no consensus on the definition of acute-on-chronic liver failure. European (EASL-CLIF) and North American (NACSELD) consortia have each proposed a commonly used definition. In this study, we compared the prevalence and short-term (30-day) mortality based on these definitions. Using a very large data set, we observed that there was a significant discordance in the prevalence and mortality based on these criteria. EASL-CLIF criteria appeared to be more sensitive to identify acute-on-chronic liver failure, and were better at predicting all-cause and short-term mortality.

Development and validation of a new prognostic score for hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND & AIMS

Early determination of the prognosis of patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is important to guide clinical management and decrease mortality. The aim of this study was to develop a new simplified prognostic score to accurately predict outcomes in patients with HBV-ACLF.

METHODS

Prospective clinical data from 2,409 hospitalized patients with acute deterioration of HBV-related chronic liver disease were used to develop a new prognostic score that was validated in an external group.

RESULTS

A total of 954 enrolled patients with HBV-ACLF were diagnosed based on the Chinese Group on the Study of Severe Hepatitis B-ACLF (COSSH-ACLF) criteria. Six predictive factors were significantly related to 28-day mortality and constituted a new prognostic score (=1.649×ln(international normalized ratio)+0.457×hepatic encephalopathy score+0.425×ln(neutrophil)+0.396×ln(total bilirubin)+0.576×ln(serum urea)+0.033×age). The C-indices of the new score for 28-/90-day mortality (0.826/0.809) were significantly higher than those of 4 other scores (COSSH-ACLF, 0.793/0.784; CLIF-C ACLF, 0.792/0.770; MELD, 0.731/0.727; MELD-Na, 0.730/0.726; all p <0.05). The prediction error rates of the new score for 28-day mortality were significantly lower than those of the 4 other scores: COSSH-ACLF (15.9%), CLIF-C ACLF (16.3%), MELD (35.3%) and MELD-Na (35.6%). The probability density function evaluation and risk stratification of the new score also showed the highest predictive values for mortality. These results were then validated in an external cohort.

CONCLUSION

A new prognostic score based on 6 predictors, without an assessment of organ failure, can accurately predict short-term mortality in patients with HBV-ACLF and might be used to guide clinical management.

LAY SUMMARY

Hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) is a complex syndrome that is associated with a high short-term mortality rate. We developed a simplified prognostic score for patients suffering from this condition based on a prospective multicentre cohort. This new score had better predictive ability than 4 other commonly used scores.

Role of L3-PMI in prognostic evaluation of patients with acute-on-chronic liver failure related to hepatitis B cirrhosis

BACKGROUND

Sarcopenia has received widespread attention in patients with end-stage liver disease since it is an independent risk factor for death and is closely related to the prognosis of the patients. However, there is still a lack of unified detection methods and diagnostic criteria for sarcopenia.

AIM

To evaluate the relationship between the third lumbar psoas muscle index (L3-PMI) and clinical indicators in patients with acute-on-chronic liver failure (ACLF) associated with hepatitis B cirrhosis and its role in prognostic evaluation.

METHODS

A retrospective study was performed on 140 patients who were hospitalized at the Department of Hepatology, Tianjin Third Central Hospital from January 2014 to December 2017, met the ACLF diagnostic criteria for hepatitis B cirrhosis, and had abdominal CT data. The same researcher manually tracked the level of the lower edge of the third lumbar vertebra on the CT images of the patient's abdomen, measured the maximum anteroposterior and transverse diameters of the psoas major on both sides, and calculated the psoas major index. The relationship of L3-PMI with clinical characteristics and prognosis was then analyzed.

RESULTS

The 140 patients were divided into a survival group with 102 cases and a death group with 38 cases according to their 90-d survival status. The L3-PMI value of patients in the death group was 4.89 cm²/m² ± 1.42 cm²/m², significantly lower than that of patients in the survival group (5.94 cm²/m² ± 1.24 cm²/m²; P < 0.001). There was no statistical difference between the two groups in PLT, ALB, ALT, AST, SCr, or eGFR (P > 0.05). The WBC, INR, and MELD scores of the death group were significantly higher than those of the survival group, while the serum sodium was significantly lower than that of the survival group (P < 0.05). In addition, 33 ACLF patients with hepatic encephalopathy (HE) had an L3-PMI value of 5.17 cm²/m² ± 1.49 cm²/m², which was significantly lower than that of 107 patients without HE (P = 0.020). Among all ACLF patients, there were 120 males and 20 females. The L3-PMI value of the male group (5.92 cm²/m² ± 1.23 cm²/m²) was significantly higher than that of the female group (4.03 cm²/m² ± 0.92 cm²/m²; P < 0.05). The ROC curve of L3-PMI for predicting death by gender was plotted. The area under the ROC curve for males was 0.726, the cut-off value was 5.02, and the sensitivity and specificity were 85% and 50%, respectively. The area under the ROC curve for females was 0.774, the cut-off value was 4.60, and the sensitivity and specificity were 50% and 100%, respectively.

CONCLUSION

L3-PMI has important clinical application value for evaluating the prognosis of ACLF patients related to hepatitis B liver cirrhosis.

Acute-on-Chronic Liver Failure in Cirrhosis

Acute-on-chronic liver failure (ACLF) is a syndrome that develops in patients with acutely decompensated chronic liver disease. It is characterised by high 28-day mortality, the presence of one or more organ failures (OFs) and a variable but severe grade of systemic inflammation. Despite the peculiarity of each one, every definition proposed for ACLF recognizes it as a proper clinical entity. In this paper, we provide an overview of the diagnostic criteria proposed by the different scientific societies and the clinical characteristics of the syndrome. Established and experimental treatments are also described. Among the former, the most relevant are directed to support organ failures, treat precipitating factors and carry out early assessment for liver transplantation (LT). Further studies are needed to better clarify pathophysiology of the syndrome and discover new therapies.

Liver Transplantation in Patients with Acute-onChronic Liver Failure: Challenging the Limits

Acute-on-chronic liver failure (ACLF) is one of the main causes of death on the waiting list. Liver transplantation (LT) is the only curative treatment for patients with ACLF and therefore it should be considered in all cases. However, the applicability of LT in patients with ACLF is challenging, given the scarcity of donors and the high short-term mortality of these patients. Organ allocation has traditionally been prioritised according to the model for end-stage liver disease (MELD) system. However, the accuracy of MELD score is limited in patients with ACLF. In this article, the authors review the outcomes of patients with ACLF before and after LT, highlighting its clinical course, the feasibility of LT in the sickest patients, the role of the organ allocation system, and possible indicators of futility.

New Indications for Liver Transplantation

Liver transplantation (LT) is an important therapeutic option for the treatment of several liver diseases. Modern LT is characterized by remarkable improvements in post-transplant patient survival, graft survival, and quality of life. Thanks to these great improvements, indications for LT are expanding. Nowadays, clinical conditions historically considered exclusion criteria for LT, have been considered new indications for LT, showing survival advantages for patients. In this review, we provide an updated overview of the principal newer indications for LT, with particular attention to alcoholic hepatitis, acute-on-chronic liver failure (ACLF), cholangiocarcinoma and colorectal cancer metastases.