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Correa CG, Colombo BDS, Ronsoni MF, Soares e Silva PE, Fayad L, Silva TE, Wildner LM, Bazzo ML, Dantas-Correa EB, Narciso-Schiavon JL, Schiavon LDL. Circulating insulin-like growth factor-binding protein 3 as prognostic biomarker in liver cirrhosis. World J Hepatol 2016; 8:739-748. [PMID: 27330683 PMCID: PMC4911508 DOI: 10.4254/wjh.v8.i17.739] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2016] [Revised: 05/03/2016] [Accepted: 05/27/2016] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate the prognostic significance of insulin-like growth factor-binding protein 3 (IGFBP-3) in patients with cirrhosis.
METHODS: Prospective study that included two cohorts: outpatients with stable cirrhosis (n = 138) and patients hospitalized for acute decompensation (n = 189). Development of complications, mortality or liver transplantation was assessed by periodical phone calls and during outpatient visits. The cohort of stable cirrhosis also underwent clinical and laboratory evaluation yearly (2013 and 2014) in predefined study visits. In patients with stable cirrhosis, IGFBP-3 levels were measured at baseline (2012) and at second re-evaluation (2014). In hospitalized subjects, IGFBP-3 levels were measured in serum samples collected in the first and in the third day after admission and stored at -80 °C. IGFBP-3 levels were measured by immunochemiluminescence.
RESULTS: IGFBP-3 levels were lower in hospitalized patients as compared to outpatients (0.94 mcg/mL vs 1.69 mcg/mL, P < 0.001) and increased after liver transplantation (3.81 mcg/mL vs 1.33 mcg/mL, P = 0.008). During the follow-up of the stable cohort, 17 patients died and 11 received liver transplantation. Bivariate analysis showed that death or transplant was associated with lower IGFBP-3 levels (1.44 mcg/mL vs 1.74 mcg/mL, P = 0.027). The Kaplan-Meier transplant-free survival probability was 88.6% in patients with IGFBP-3 ≥ 1.67 mcg/mL and 72.1% for those with IGFBP3 < 1.67 mcg/mL (P = 0.015). In the hospitalized cohort, 30-d mortality was 24.3% and was independently associated with creatinine, INR, SpO2/FiO2 ratio and IGFBP-3 levels in the logistic regression. The 90-d transplant-free survival probability was 80.4% in patients with IGFBP-3 ≥ 0.86 mcg/mL and 56.1% for those with IGFBP3 < 0.86 mcg/mL (P < 0.001).
CONCLUSION: Lower IGFBP-3 levels were associated with worse outcomes in patients with cirrhosis, and might represent a promising prognostic tool that can be incorporated in clinical practice.
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Abstract
The definition of acute-on-chronic liver failure (ACLF) remains contested. In Europe and North America, the term is generally applied according to the European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) Consortium guidelines, which defines this condition as a syndrome that develops in patients with cirrhosis and is characterized by acute decompensation, organ failure and high short-term mortality. One-third of patients who are hospitalized for acute decompensation present with ACLF at admission or develop the syndrome during hospitalization. ACLF frequently occurs in a closed temporal relationship to a precipitating event, such as bacterial infection or acute alcoholic, drug-induced or viral hepatitis. However, no precipitating event can be identified in approximately 40% of patients. The mechanisms of ACLF involve systemic inflammation due to infections, acute liver damage and, in cases without precipitating events, probably intestinal translocation of bacteria or bacterial products. ACLF is graded into three stages (ACLF grades 1-3) on the basis of the number of organ failures, with higher grades associated with increased mortality. Liver and renal failures are the most common organ failures, followed by coagulation, brain, circulatory and respiratory failure. The 28-day mortality rate associated with ACLF is 30%. Depending on the grade, ACLF can be reversed using standard therapy in only 16-51% of patients, leaving a considerable proportion of patients with ACLF that remains steady or progresses. Liver transplantation in selected patients with ACLF grade 2 and ACLF grade 3 increases the 6-month survival from 10% to 80%.
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Jeong JH, Park IS, Kim DH, Kim SC, Kang C, Lee SH, Kim TY, Lee SB. CLIF-SOFA score and SIRS are independent prognostic factors in patients with hepatic encephalopathy due to alcoholic liver cirrhosis. Medicine (Baltimore) 2016; 95:e3935. [PMID: 27367990 PMCID: PMC4937904 DOI: 10.1097/md.0000000000003935] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Hepatic encephalopathy (HE) is a complication associated with worst prognosis in decompensated liver cirrhosis (LC) patients. Previous studies have identified prognostic factors for HE, and recent studies reported an association between systemic inflammatory response syndrome (SIRS) and liver disease. This study aimed to identify prognostic factors for 30-day mortality in alcoholic LC patients with HE who visited the emergency department (ED).This was a retrospective study of alcoholic LC patients with HE from January 1, 2010, to April 30, 2015. The baseline characteristics, complications of portal hypertension, laboratory values, Child-Pugh class, Model for End-stage Liver Disease (MELD) score, chronic liver failure-sequential organ failure assessment (CLIF-SOFA) score, and SIRS criteria were assessed. The presence of 2 or more SIRS criteria was considered SIRS. The primary outcomes were 30-day mortality and prognostic factors for patients with HE visiting the ED.In total, 105 patients who met the inclusion criteria were analyzed. Overall, the 30-day mortality rate was 6.7% (7 patients).Significant variables were hepatorenal syndrome, international normalized ratio, white blood cell count, total bilirubin level, MELD score CLIF-SOFA score, and SIRS in univariate analysis. CLIF-SOFA score and SIRS were the significant factors in the multivariate analysis (hazard ratio 5.56, 15.98; 95% confidence interval 1.18-26.18, 1.58-161.37; P = 0.03, P = 0.02). The mortality rates differed according to the CLIF-SOFA score (P < 0.01).The CLIF-SOFA score and SIRS in alcoholic LC patients with HE visiting the ED are independent predictors of 30-day mortality.
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Affiliation(s)
- Jin Hee Jeong
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - In Sung Park
- Department of Neurosurgery, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
- Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
- Correspondence: In Sung Park, Department of Neurosurgery, Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea, Gyeongsang Institute of Health Sciences, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea (e-mail: )
| | - Dong Hoon Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Seong Chun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Changwoo Kang
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Soo Hoon Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Tae Yun Kim
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
| | - Sang Bong Lee
- Department of Emergency Medicine, Gyeongsang National University School of Medicine, Jinju-si, Gyeongsangnam-do, Republic of Korea
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Characteristics, Diagnosis and Prognosis of Acute-on-Chronic Liver Failure in Cirrhosis Associated to Hepatitis B. Sci Rep 2016; 6:25487. [PMID: 27146801 PMCID: PMC4857102 DOI: 10.1038/srep25487] [Citation(s) in RCA: 105] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2015] [Accepted: 04/18/2016] [Indexed: 02/07/2023] Open
Abstract
The diagnostic and prognostic criteria of acute-on-chronic liver failure (ACLF) were developed in patients with no Hepatitis B virus (HBV) cirrhosis (CANONIC study). The aims of this study were to evaluate whether the diagnostic (CLIF-C organ failure score; CLIF-C OFs) criteria can be used to classify patients; and the prognostic score (CLIF-C ACLF score) could be used to provide prognostic information in HBV cirrhotic patients with ACLF. 890 HBV associated cirrhotic patients with acute decompensation (AD) were enrolled. Using the CLIF-C OFs, 33.7% (300 patients) were diagnosed as ACLF. ACLF was more common in the younger patients and in those with no previous history of decompensation. The most common organ failures were ‘hepatic’ and ‘coagulation’. As in the CANONIC study, 90-day mortality was extremely low in the non-ACLF patients compared with ACLF patients (4.6% vs 50%, p < 0.0001). ACLF grade and white cell count, were independent predictors of mortality. CLIF-C ACLFs accurately predicted short-term mortality, significantly better than the MELDs and a disease specific score generated for the HBV patients. Current study indicates that ACLF is a clinically and pathophysiology distinct even in HBV patients. Consequently, diagnostic criteria, prognostic scores and probably the management of ACLF should base on similar principles.
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Zhang J, Gao S, Duan Z, Hu KQ. Overview on acute-on-chronic liver failure. Front Med 2016; 10:1-17. [PMID: 26976617 DOI: 10.1007/s11684-016-0439-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 01/28/2016] [Indexed: 12/11/2022]
Abstract
Liver failure (LF) is defined as severe dysfunction in hepatic synthesis, detoxification, and metabolism induced by various etiologies. Clinical presentation of LF typically includes severe jaundice, coagulation disorder, hepatic encephalopathy, and ascites. LF can be classified into acute LF, acute-on-chronic LF (ACLF), and chronic LF. ACLF has been demonstrated as a distinct syndrome with unique clinical presentation and outcomes. The severity, curability, and reversibility of ACLF have attracted considerable attention. Remarkable developments in ACLF-related conception, diagnostic criteria, pathogenesis, and therapy have been achieved. However, this disease, especially its diagnostic criteria, remains controversial. In this paper, we systemically reviewed the current understanding of ACLF from its definition, etiology, pathophysiology, pathology, and clinical presentation to management by thoroughly comparing important findings between east and west countries, as well as those from other regions. We also discussed the controversies, challenges, and needs for future studies to promote the standardization and optimization of the diagnosis and treatment for ACLF.
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Affiliation(s)
- Jing Zhang
- Department of Hepatitis C and Drug Induced Liver Injury, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
- Collaborative Innovation Center of Infectious Diseases, Beijing, 100069, China
| | - Shan Gao
- Beijing Artificial Liver Treatment & Training Center, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China
- Collaborative Innovation Center of Infectious Diseases, Beijing, 100069, China
| | - Zhongping Duan
- Beijing Artificial Liver Treatment & Training Center, Beijing YouAn Hospital, Capital Medical University, Beijing, 100069, China.
- Collaborative Innovation Center of Infectious Diseases, Beijing, 100069, China.
| | - Ke-Qin Hu
- Division of Gastroenterology and Hepatology, University of California, Irvine, Medical Center, Orange, CA, 92868, USA.
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Sarin SK, Choudhury A. Acute-on-chronic liver failure: terminology, mechanisms and management. Nat Rev Gastroenterol Hepatol 2016; 13:131-49. [PMID: 26837712 DOI: 10.1038/nrgastro.2015.219] [Citation(s) in RCA: 231] [Impact Index Per Article: 28.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Acute-on-chronic liver failure (ACLF) is a distinct clinical entity and differs from acute liver failure and decompensated cirrhosis in timing, presence of acute precipitant, course of disease and potential for unaided recovery. The definition involves outlining the acute and chronic insults to include a homogenous patient group with liver failure and an expected outcome in a specific timeframe. The pathophysiology of ACLF relates to persistent inflammation, immune dysregulation with initial wide-spread immune activation, a state of systematic inflammatory response syndrome and subsequent sepsis due to immune paresis. The disease severity and outcome can be predicted by both hepatic and extrahepatic organ failure(s). Clinical recovery is expected with the use of nucleoside analogues for hepatitis B, and steroids for severe alcoholic hepatitis and, possibly, severe autoimmune hepatitis. Artificial liver support systems help remove toxins and metabolites and serve as a bridge therapy before liver transplantation. Hepatic regeneration during ongoing liver failure, although challenging, is possible through the use of growth factors. Liver transplantation remains the definitive treatment with a good outcome. Pre-emptive antiviral agents for hepatitis B before chemotherapy to prevent viral reactivation and caution in using potentially hepatotoxic drugs can prevent the development of ACLF.
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Affiliation(s)
- Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
| | - Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, D-1, Vasant Kunj, New Delhi 110070, India
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Bao Q, Wang B, Yu L, Weng H, Ge J, Li L. A modified prognostic score for critically ill patients with cirrhosis: An observational study. J Gastroenterol Hepatol 2016; 31:450-8. [PMID: 26251873 DOI: 10.1111/jgh.13076] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Revised: 07/11/2015] [Accepted: 08/01/2015] [Indexed: 12/20/2022]
Abstract
BACKGROUND AND AIMS It is controversial whether patients with cirrhosis benefit from the intensive care unit (ICU) management. To identify the patients in whom ICU care may offer recovery, this study aimed to determine specific risk factors and to establish a novel prognostic score for 3-month mortality in critically ill patients with cirrhosis. METHODS An observational study was performed from August 2008 to May 2014, encompassing 349 critically ill patients with cirrhosis during their ICU stay (a 70% training and 30% validation set). RESULTS The overall 3-month mortality rate was 68.1% in training cohort. Prothrombin time, serum bilirubin, use of vasopressors, hepatic encephalopathy, and systemic inflammatory response syndrome at admission were identified as being strongly correlated with the 3-month prognosis. Based on these five variables, a modified score for critically ill cirrhosis (MSCIC) was developed. An increasing MSCIC was significantly correlated with a reduction in the rate of survival (P < 0.001). Moreover, excellent predictive power was found when the MSCIC was used (area under the receiver operating characteristic curve: 0.856 ± 0.047), which was significantly better than the prognostic efficiency of Acute Physiology and Chronic Health Evaluation II (P < 0.001), Model for End-stage Liver Disease (P = 0.02), Simplified Acute Physiology Score (P = 0.023), and the Child-Turcotte-Pugh score (P = 0.01); the MSCIC score was slightly better than that of Chronic Liver Failure-Sequential Organ Failure Assessment (P = 0.068). The similar result was obtained in validation set. CONCLUSIONS The MSCIC is an easily adopted tool with a high prognostic efficacy for patients with advanced cirrhosis; MSCIC may act as a supplement to the clinical judgment of physicians when considering the prognosis.
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Affiliation(s)
- Qiongling Bao
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Baohong Wang
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Liang Yu
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Honglei Weng
- Department of Medicine II, Section Molecular Hepatology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Jianping Ge
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
| | - Lanjuan Li
- State Key Laboratory for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University.,Collaborative Innovation Center for Diagnosis and Treatment of Infectious Diseases, Hangzhou, China
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Kim TY, Song DS, Kim HY, Sinn DH, Yoon EL, Kim CW, Jung YK, Suk KT, Lee SS, Lee CH, Kim TH, Kim JH, Choe WH, Yim HJ, Kim SE, Baik SK, Lee BS, Jang JY, Suh JI, Kim HS, Nam SW, Kwon HC, Kim YS, Kim SG, Chae HB, Yang JM, Sohn JH, Lee HJ, Park SH, Han BH, Choi EH, Kim CH, Kim DJ. Characteristics and Discrepancies in Acute-on-Chronic Liver Failure: Need for a Unified Definition. PLoS One 2016; 11:e0146745. [PMID: 26789409 PMCID: PMC4720429 DOI: 10.1371/journal.pone.0146745] [Citation(s) in RCA: 35] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2015] [Accepted: 12/20/2015] [Indexed: 02/07/2023] Open
Abstract
Background & Aim To investigate the prevalence, mortalities, and patient characteristics of Acute-on-chronic liver failure (ACLF) according to the AARC (Asian Pacific Association for the Study of the Liver ACLF Research Consortium) and European Association for the Study of the Liver CLIF-C (Chronic Liver Failure Consortium) definitions. Methods We collected retrospective data for 1470 hospitalized patients with chronic liver disease (CLD) and acute deterioration between January 2013 and December 2013 from 21 university hospitals in Korea. Results Of the patients assessed, the prevalence of ACLF based on the AARC and CLIF-C definitions was 9.5% and 18.6%, respectively. The 28-day and 90-day mortality rates were higher in patients with ACLF than in those without ACLF. Patients who only met the CLIF-C definition had significantly lower 28-day and 90-day survival rates than those who only met the AARC definition (68.0% vs. 93.9%, P<0.001; 55.1% vs. 92.4%, P<0.001). Among the patients who had non-cirrhotic CLD, the 90-day mortality of the patients with ACLF was higher than of those without ACLF, although not significant (33.3% vs. 6.0%, P = 0.192). Patients with previous acute decompensation (AD) within 1- year had a lower 90-day survival rate than those with AD more than 1 year prior or without previous AD (81.0% vs. 91.9% or 89.4%, respectively, all P<0.001). Patients who had extra-hepatic organ failure without liver failure had a similar 90-day survival rate to those who had liver failure as a prerequisite (57.0% vs. 60.6%, P = 0.391). Conclusions The two ACLF definitions result in differences in mortality and patient characteristics among ACLF patients. We suggest that non-cirrhotic CLD, previous AD within 1 year, and extra-hepatic organ failure should be included in the ACLF diagnostic criteria. In addition, further studies are necessary to develop a universal definition of ACLF.
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Affiliation(s)
- Tae Yeob Kim
- Institute of Medical Science, Hanyang University, Seoul, Republic of Korea
| | - Do Seon Song
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Hee Yeon Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Dong Hyun Sinn
- Department of Internal Medicine, Samsung Medical Center, Seoul, Republic of Korea
| | - Eileen L. Yoon
- Department of Internal Medicine, Inje University Sanggye Paik Hospital, Seoul, Republic of Korea
| | - Chang Wook Kim
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Young Kul Jung
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Ki Tae Suk
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
| | - Sang Soo Lee
- Department of Internal Medicine, Gyeongsang National University Hospital, Jinju, Republic of Korea
| | - Chang Hyeong Lee
- Department of Internal Medicine, Catholic University of Daegu School of Medicine, Daegu, Republic of Korea
| | - Tae Hun Kim
- Department of Internal Medicine, Ewha Womans University School of Medicine, Seoul, Republic of Korea
| | - Jeong Han Kim
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Won Hyeok Choe
- Department of Internal Medicine, Konkuk University School of Medicine, Seoul, Republic of Korea
| | - Hyung Joon Yim
- Department of Internal Medicine, Korea University Ansan Hospital, Ansan, Republic of Korea
| | - Sung Eun Kim
- Department of Internal Medicine, Hallym University Sacred Heart Hospital, Anyang, Republic of Korea
| | - Soon Koo Baik
- Department of Internal Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Byung Seok Lee
- Department of Internal Medicine, Chungnam National University, School of Medicine, Daejeon, Republic of Korea
| | - Jae Young Jang
- Department of Internal Medicine, Soonchunhyang University College of Medicine, Seoul, Republic of Korea
| | - Jeong Ill Suh
- Department of Internal Medicine, Dongguk University Gyeongju Hospital, Gyeongju, Republic of Korea
| | - Hyoung Su Kim
- Department of Internal Medicine, Hallym University Kangdong Sacred Heart Hospital, Seoul, Republic of Korea
| | - Seong Woo Nam
- Department of Internal medicine, National Medical Center, Seoul, Republic of Korea
| | - Hyeok Choon Kwon
- Department of Internal medicine, National Medical Center, Seoul, Republic of Korea
| | - Young Seok Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Sang Gyune Kim
- Department of Internal Medicine, Soonchunhyang University Bucheon Hospital, Bucheon, Republic of Korea
| | - Hee Bok Chae
- Department of Internal medicine, College of Medicine and Medical Research Institute, Chungbuk National University, Cheongju, Republic of Korea
| | - Jin Mo Yang
- Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, Republic of Korea
| | - Joo Hyun Sohn
- Department of Internal Medicine, Hanyang University Guri Hospital, Guri, Republic of Korea
| | - Heon Ju Lee
- Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Seung Ha Park
- Department of Internal Medicine, Inje University Haeundae Paik-Hospital, Inje University College of Medicine, Busan, Republic of Korea
| | - Byung Hoon Han
- Department of Internal Medicine, Kosin University College of Medicine, Busan, Republic of Korea
| | - Eun Hee Choi
- Institute of Lifestyle Medicine, Yonsei University Wonju College of Medicine, Wonju, Republic of Korea
| | - Chang H. Kim
- Department of Internal Medicine, University Hospitals Case Medical Center, Cleveland, Ohio, United States of America
| | - Dong Joon Kim
- Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Republic of Korea
- * E-mail:
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Blasco-Algora S, Masegosa-Ataz J, Gutiérrez-García ML, Alonso-López S, Fernández-Rodríguez CM. Acute-on-chronic liver failure: Pathogenesis, prognostic factors and management. World J Gastroenterol 2015; 21:12125-40. [PMID: 26576097 PMCID: PMC4641130 DOI: 10.3748/wjg.v21.i42.12125] [Citation(s) in RCA: 47] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2015] [Revised: 08/17/2015] [Accepted: 09/30/2015] [Indexed: 02/06/2023] Open
Abstract
Acute-on-chronic liver failure (ACLF) is increasingly recognized as a complex syndrome that is reversible in many cases. It is characterized by an acute deterioration of liver function in the background of a pre-existing chronic liver disease often associated with a high short-term mortality rate. Organ failure (OF) is always associated, and plays a key role in determining the course, and the outcome of the disease. The definition of ACLF remains controversial due to its overall ambiguity, with several disparate criteria among various associations dedicated to the study of liver diseases. Although the precise pathogenesis needs to be clarified, it appears that an altered host response to injury might be a contributing factor caused by immune dysfunction, ultimately leading to a pro-inflammatory status, and eventually to OF. The PIRO concept (Predisposition, Insult, Response and Organ Failure) has been proposed to better approach the underlying mechanisms. It is accepted that ACLF is a different and specific form of liver failure, where a precipitating event is always involved, even though it cannot always be ascertained. According to several studies, infections and active alcoholism often trigger ACLF. Viral hepatitis, gastrointestinal haemorrhage, or drug induced liver injury, which can also provoke the syndrome. This review mainly focuses on the physiopathology and prognostic aspects. We believe these features are essential to further understanding and providing the rationale for improveddisease management strategies.
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Abstract
Patients with cirrhosis and portal hypertension are at an increased risk of the development of circulatory dysfunction that may potentially result in multiple organ failure. Apart from the liver, this may involve the heart, lungs, kidneys, the immune system, the adrenal glands, and other organ systems. As the disease progresses, the circulation becomes hyperdynamic, and signs of cardiac, pulmonary, and renal dysfunction are observed, in addition to reduced survival. Infections and an altered cardiac function known as cirrhotic cardiomyopathy may be precipitators for the development of other complications such as hepatorenal syndrome. In patients with chronic organ dysfunction, various precipitating events may induce an acute-on-chronic renal failure and acute-on-chronic liver failure that negatively affect the prognosis. Future research on the pathophysiologic mechanisms of the complications and the precipitating factors is essential to understand the basics of the treatment of these challenging conditions. The aim of the present review is to focus on the development and precipitating factors of various organ failures in patients with decompensated cirrhosis.
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Goossens N, Nakagawa S, Hoshida Y. Molecular prognostic prediction in liver cirrhosis. World J Gastroenterol 2015; 21:10262-10273. [PMID: 26420954 PMCID: PMC4579874 DOI: 10.3748/wjg.v21.i36.10262] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/25/2015] [Revised: 06/12/2015] [Accepted: 08/31/2015] [Indexed: 02/06/2023] Open
Abstract
The natural history of cirrhosis varies and therefore prognostic prediction is critical given the sizable patient population. A variety of clinical prognostic indicators have been developed and enable patient risk stratification although their performance is somewhat limited especially within relatively earlier stage of disease. Molecular prognostic indicators are expected to refine the prediction, and potentially link a subset of patients with molecular targeted interventions that counteract poor prognosis. Here we overview clinical and molecular prognostic indicators in the literature, and discuss critical issues to successfully define, evaluate, and deploy prognostic indicators as clinical scores or tests. The use of liver biopsy has been diminishing due to sampling variability on fibrosis assessment and emergence of imaging- or lab test-based fibrosis assessment methods. However, recent rapid developments of genomics technologies and selective molecular targeted agents has highlighted the need for biopsy tissue specimen to explore and establish molecular information-guided personalized/stratified clinical care, and eventually achieve “precision medicine”.
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Shi Y, Yang Y, Hu Y, Wu W, Yang Q, Zheng M, Zhang S, Xu Z, Wu Y, Yan H, Chen Z. Acute-on-chronic liver failure precipitated by hepatic injury is distinct from that precipitated by extrahepatic insults. Hepatology 2015; 62:232-42. [PMID: 25800029 DOI: 10.1002/hep.27795] [Citation(s) in RCA: 215] [Impact Index Per Article: 23.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2014] [Accepted: 03/15/2015] [Indexed: 12/11/2022]
Abstract
UNLABELLED Patients with acute-on-chronic liver failure (ACLF) represent a heterogeneous population. The aim of the study is to identify distinct groups according to the etiologies of precipitating events. A total of 405 ACLF patients were identified from 1,361 patients with cirrhosis with acute decompensation and categorized according to the types of acute insults. Clinical characteristics and prognosis between the hepatic group and extrahepatic group were compared, and the performance of prognostic models was tested in different groups. Two distinct groups (hepatic-ACLF and extrahepatic-ACLF) were identified among the ACLF population. Hepatic-ACLF was precipitated by hepatic insults and had relatively well-compensated cirrhosis with frequent liver and coagulation failure. In contrast, extrahepatic-ACLF was exclusively precipitated by extrahepatic insults, characterized by more severe underlying cirrhosis and high occurrence of extrahepatic organ failures (kidney, cerebral, circulation, and respiratory systems). Both groups had comparably high short-term mortality (28-day transplant-free mortality: 48.3% vs. 50.7%; P = 0.22); however, the extra-hepatic-ACLF group had significantly higher 90-day and 1-year mortality (90-day: 58.9% vs. 68.3%, P = 0.035; 1-year: 63.9% vs. 74.6%, P = 0.019). In hepatic-ACLF group, the integrated Model for End-Stage Liver Disease (iMELD) score had the highest area under the receiver operating characteristic curve (auROC = 0.787) among various prognostic models in predicting 28-day mortality, whereas CLIF-Consortium scores for ACLF patients (CLIF-C-ACLF) had the highest predictive value in the other group (auROC = 0.779). CONCLUSIONS ACLF precipitated by hepatic insults is distinct from ACLF precipitated by extrahepatic insults in clinical presentation and prognosis. The iMELD score may be a better predictor for hepatic-ACLF short-term prognosis, whereas CLIF-C-ACLF may be better for extrahepatic-ACLF patients.
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Affiliation(s)
- Yu Shi
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Ying Yang
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Yaoren Hu
- Department of Hepatology, Ningbo No. 2 Hospital, Ningbo, China
| | - Wei Wu
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Qiao Yang
- Department of Infectious Diseases, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Min Zheng
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
| | - Shun Zhang
- Stem Cell Laboratory, Ningbo No. 2 Hospital, Ningbo, China
| | - Zhaojun Xu
- Department of Intensive Care Unit, Ningbo No. 2 Hospital, Ningbo, China
| | - Yihua Wu
- Department of Epidemiology and Health Statistics, Zhejiang University School of Public Health, Hangzhou, China
| | - Huadong Yan
- Department of Hepatology, Ningbo No. 2 Hospital, Ningbo, China
| | - Zhi Chen
- State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, Collaborative Innovation Center for Diagnosis and Treatment of Infectious Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
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Schiavon LL, Narciso-Schiavon JL. Benefits of beta-blockers for patients with cirrhosis and infection: do not celebrate too soon! Liver Int 2015; 35:1777-8. [PMID: 25664375 DOI: 10.1111/liv.12800] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/13/2023]
Affiliation(s)
- Leonardo L Schiavon
- Department of Internal Medicine, Federal University of Santa Catarina, Florianopolis, Brazil
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64
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Pattern and profile of chronic liver disease in acute on chronic liver failure. Hepatol Int 2015; 9:366-72. [PMID: 26016461 DOI: 10.1007/s12072-015-9627-z] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2014] [Accepted: 03/30/2015] [Indexed: 12/19/2022]
Abstract
The etiology of the chronic liver disease (CLD) in patients with acute on chronic liver failure (ACLF) may vary from region to region. The major cause of underlying CLD is viral (hepatitis B and C) in the East, while it is alcohol related in the West and in some parts of the Indian subcontinent. Autoimmune liver disease and Wilson's disease are the major underlying etiologies in the pediatric age group. The patients with CLD without cirrhosis should be included when defining ACLF. Non-alcoholic fatty liver disease related chronic liver insult in patients with known risk factors for progressive disease should be taken as a chronic liver disease in the setting of ACLF, whereas fatty liver with normal aminotransferases in low risk patients should not. The patients with CLD and previous decompensation should be excluded. Diagnosis of chronic liver disease in the setting of ACLF is made by history, physical examination and previously available or recent laboratory, endoscopic or radiological investigations. A liver biopsy through the transjugular route may help in cases where the presence of underlying CLD or its cause is not clear. The need of liver biopsy in ACLF should, however, be individualized. Standardization of liver biopsy assessment is essential for a uniform approach to the diagnosis and treatment of CLD and acute insult. Tools to measure liver stiffness may aid in identifying patients with advanced fibrosis. Studies are needed to validate the performance of these tests in the setting of ACLF.
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Pinto RB, Schneider ACR, da Silveira TR. Cirrhosis in children and adolescents: An overview. World J Hepatol 2015; 7:392-405. [PMID: 25848466 PMCID: PMC4381165 DOI: 10.4254/wjh.v7.i3.392] [Citation(s) in RCA: 59] [Impact Index Per Article: 6.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/09/2014] [Revised: 12/10/2014] [Accepted: 01/09/2015] [Indexed: 02/06/2023] Open
Abstract
Several conditions, especially chronic liver diseases, can lead to cirrhosis in children and adolescents. Most cases in clinical practice are caused by similar etiologies. In infants, cirrhosis is most often caused by biliary atresia and genetic-metabolic diseases, while in older children, it tends to result from autoimmune hepatitis, Wilson's disease, alpha-1-antitrypsin deficiency and primary sclerosing cholangitis. The symptoms of cirrhosis in children and adolescents are similar to those of adults. However, in pediatric patients, the first sign of cirrhosis is often poor weight gain. The complications of pediatric cirrhosis are similar to those observed in adult patients, and include gastrointestinal bleeding caused by gastroesophageal varices, ascites and spontaneous bacterial peritonitis. In pediatric patients, special attention should be paid to the nutritional alterations caused by cirrhosis, since children and adolescents have higher nutritional requirements for growth and development. Children and adolescents with chronic cholestasis are at risk for several nutritional deficiencies. Malnutrition can have severe consequences for both pre- and post-liver transplant patients. The treatment of cirrhosis-induced portal hypertension in children and adolescents is mostly based on methods developed for adults. The present article will review the diagnostic and differential diagnostic aspects of end-stage liver disease in children, as well as the major treatment options for this condition.
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Affiliation(s)
- Raquel Borges Pinto
- Raquel Borges Pinto, Pediatric Gastroenterology Unit, Hospital da Criança Conceição, Porto Alegre 91340 480, Rio Grande do Sul, Brazil
| | - Ana Claudia Reis Schneider
- Raquel Borges Pinto, Pediatric Gastroenterology Unit, Hospital da Criança Conceição, Porto Alegre 91340 480, Rio Grande do Sul, Brazil
| | - Themis Reverbel da Silveira
- Raquel Borges Pinto, Pediatric Gastroenterology Unit, Hospital da Criança Conceição, Porto Alegre 91340 480, Rio Grande do Sul, Brazil
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Fayad L, Narciso-Schiavon JL, Lazzarotto C, Ronsoni MF, Wildner LM, Bazzo ML, Schiavon LDL, Dantas-Corrêa EB. The performance of prognostic models as predictors of mortality in patients with acute decompensation of cirrhosis. Ann Hepatol 2015. [PMID: 25536645 DOI: 10.1016/s1665-2681(19)30804-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Although several prognostic models have been proposed for cirrhotic patients listed for transplantation, the performance of these scores as predictors of mortality in patients admitted for acute decompensation of cirrhosis has not been satisfactorily investigated. AIMS To study MELD, MELD-Na, MESO, iMELD, Refit-MELD and Refit MELD-Na models as prognostic predictors in cirrhotic patients admitted for acute decompensation, and to compare their performance between admission and 48 hours of hospitalization to predict in-hospital mortality. MATERIAL AND METHODS This cohort study included cirrhotic patients admitted to hospital due to complications of the disease. Individuals were evaluated on admission and after 48 h of hospitalization, and mortality was evaluated during the present admission. RESULTS One hundred and twenty-three subjects with a mean age of 54.26 ± 10.79 years were included; 76.4% were male. Mean MELD score was 16.43 ± 7.08 and 52.0% of patients were Child-Pugh C. Twenty-seven patients (22.0%) died during hospitalization. Similar areas under the curve (AUROCs) for prognosis of mortality were observed when different models were compared on admission (P > 0.05) and after 48 h of hospitalization (P > 0.05). When models executed after 48 h of hospitalization were compared to their corresponding model calculated on admission, significantly higher AUROCs were obtained for all models (P < 0.05), except for MELD-Na (P = 0.075) and iMELD (P = 0.119). CONCLUSION The studied models showed similar accuracy as predictors of in-hospital mortality in cirrhotic patients admitted for acute decompensation. However, the performance of these models was significantly better when applied 48 h after admission when compared to their calculation on admission.
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Affiliation(s)
- Leonardo Fayad
- Department of Internal Medicine, Division of Gastroenterology, Federal University of Santa Catarina (UFSC). Brazil
| | - Janaína Luz Narciso-Schiavon
- Department of Internal Medicine, Division of Gastroenterology, Federal University of Santa Catarina (UFSC). Brazil
| | - César Lazzarotto
- Department of Internal Medicine, Division of Gastroenterology, Federal University of Santa Catarina (UFSC). Brazil
| | - Marcelo Fernando Ronsoni
- Department of Internal Medicine, Division of Gastroenterology, Federal University of Santa Catarina (UFSC). Brazil
| | | | - Maria Luiza Bazzo
- Department of Clinical Analysis, Federal University of Santa Catarina (UFSC). Brazil
| | - Leonardo de Lucca Schiavon
- Department of Internal Medicine, Division of Gastroenterology, Federal University of Santa Catarina (UFSC). Brazil
| | - Esther Buzaglo Dantas-Corrêa
- Department of Internal Medicine, Division of Gastroenterology, Federal University of Santa Catarina (UFSC). Brazil
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