Acute-on-Chronic Liver Failure (ACLF) in Coastal Eastern India: "A Single-Center Experience"

Definitions, Etiologies, and Outcomes of Acute on Chronic Liver Failure: A Systematic Review and Meta-analysis

BACKGROUND & AIMS

Acute-on-chronic liver failure (ACLF) is a major public health concern. We aimed to assess the definitions, etiologic spectrum, organ failure (OF), and outcomes of ACLF globally.

METHODS

Three databases were searched for studies on ACLF from 1990 until September 2022. Information regarding definitions, acute precipitants, underlying chronic liver disease (CLD), OF, and mortality were extracted. Meta-analyses were performed for pooled prevalence rates (95% confidence interval [CI]) using random-effects model for each definition of ACLF.

RESULTS

Of the 11,451 studies identified, 114 articles (142 cohorts encompassing 210,239 patients) met the eligibility criteria. Most studies (53.2%) used the European Association for the Study of the Liver (EASL) definition, followed by Asia-Pacific Association for the Study of the Liver (APASL) (33.3%). Systemic infection was the major acute precipitant, and alcohol use was the major cause of CLD in EASL-defined studies, whereas alcohol was both the major acute precipitant and cause of CLD in APASL-defined studies. Liver failure was the major OF in APASL-based studies, whereas renal failure was predominant in EASL-based studies. Thirty-day mortality varied across definitions: APASL: 38.9%, 95% CI, 31.2%-46.9%; EASL: 47.9%, 95% CI, 42.2%-53.5%; and NACSELD: 52.2%, 95% CI, 51.9%-52.5%. Diagnostic overlap between definitions ranged from 7.7% to 80.2%. Meta-regression suggested that the World Health Organization region influenced 30-day mortality in studies using EASL definition.

CONCLUSIONS

Heterogeneity in the definition of ACLF proposed by different expert societies and regional preferences in its use result in differences in clinical phenotype and outcomes. A uniform definition would enhance the comparability and interpretation of global data.

Tenofovir alafenamide versus entecavir for treating hepatitis B virus-related acute-on-chronic liver failure: real-world study

Background and aims

Real-world data regarding hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF) patients receiving tenofovir alafenamide (TAF) as an antiviral drug are limited. Hence, we evaluated the efficacy and kidney safety of TAF among this population.

Methods

A total of 272 HBV-related ACLF patients hospitalized at Xiangya Hospital of Central South University were enrolled in this retrospective research. All patients received antiviral therapy with TAF (n = 100) or ETV (n = 172) and comprehensive medical treatments.

Results

Through 1:1 propensity score matching, 100 patients were finally included in each group. At week 48, the survival rates without transplantation of the TAF group and ETV group were 76.00 and 58.00%, separately (P = 0.007). After 4 weeks of treatment, the TAF treatment group exhibited a significantly decline in HBV DNA viral load (P = 0.029). The mean estimated glomerular filtration rate was apparently improved in the TAF group compared with the ETV group (TAF 5.98 ± 14.46 vs. ETV 1.18 ± 18.07 ml/min/1.73 m²) (P < 0.05). There were 6 patients in TAF group and 21 patients in ETV group with chronic kidney disease (CKD) stage progression ≥ 1. By contrast, the ETV treatment group has a greater risk of renal function progression in CKD 1 stage patients (P < 0.05).

Conclusion

This real-world clinical study showed that TAF is more effective than ETV in reducing viral load and improving survival rate in HBV-ACLF patients and the risk of renal function decline is lower.

Clinical trial registration

https://ClinicalTrials.gov, identifier NCT05453448.

Early Diagnosis and Prevention of Infections in Cirrhosis

Strategies to prevent infection and improve outcomes in patients with cirrhosis. HAV, hepatitis A virus; HBV, hepatitis B virus; COVID-19, novel coronavirus disease 2019; NSBB, nonselective β-blocker; PPI, proton pump inhibitors.Cirrhosis is a risk factor for infections. Majority of hospital admissions in patients with cirrhosis are due to infections. Sepsis is an immunological response to an infectious process that leads to end-organ dysfunction and death. Preventing infections may avoid the downstream complications, and early diagnosis of infections may improve the outcomes. In this review, we discuss the pathogenesis, diagnosis, and biomarkers of infection; the incremental preventive strategies for infections and sepsi; and the consequent organ failures in cirrhosis. Strategies for primary prevention include reducing gut translocation by selective intestinal decontamination, avoiding unnecessary proton pump inhibitors' use, appropriate use of β-blockers, and vaccinations for viral diseases including novel coronavirus disease 2019. Secondary prevention includes early diagnosis and a timely and judicious use of antibiotics to prevent organ dysfunction. Organ failure support constitutes tertiary intervention in cirrhosis. In conclusion, infections in cirrhosis are potentially preventable with appropriate care strategies to then enable improved outcomes.

Baseline serum cystatin C as a marker of acute kidney injury in patients with acute-on-chronic liver failure

BACKGROUND

A creatinine-based estimation of the renal function lags behind the onset of disease process. Cystatin C is a new marker for acute kidney injury (AKI). However, data are limited in patients with acute-on-chronic liver failure (ACLF). We evaluated serum cystatin C as an early predictor of AKI in patients with ACLF.

METHODS

In a prospective observational study, patients with ACLF and normal serum creatinine level were included in the study. Serum cystatin C was analyzed with the development of AKI and the disease outcome.

RESULT

Forty-seven patients (mean age: 43.26±16.34 years; male:female: 2.35:1) were included in the study. AKI developed in 34% of patients during the hospital stay. Receiver operating characteristic (ROC) curve analysis revealed that the best cutoff for baseline cystatin C was 1.47 mg/L with a sensitivity of 0.94 and specificity of 0.68. The cystatin C ((area under the curve [AUC]=0.853) performance was better than that of the creatinine (AUC=0.699), Child-Turcotte-Pugh (CTP) (AUC=0.661), and model for end-stage liver disease-sodium (MELD-Na) (AUC=0.641). In the univariate analysis, age, platelet count, creatinine, estimated glomerular filtration rate (eGFR)-modification of diet in renal disease (MDRD), cystatin C, and estimated glomerular filtration rate-serum cystatin C (eGFRcysC) were significantly associated with AKI in ACLF patients. Cystatin C was an independent positive predictor of AKI. Cystatin C was positively correlated with the MELD-Na scores (r=0.374 and p=0.009).

CONCLUSION

Our study supports previous studies reporting that serum cystatin C is a better predictor for AKI development compared to serum creatinine. Cystatin C may be used as an early marker for new-onset AKI in hospitalized patients with ACLF.

Predictors of early mortality among patients with acute-on-chronic liver failure

Background and Aim

Acute-on-chronic liver failure (ACLF) is a transpiring entity, which possesses high short-term/early mortality (28 days). Several mortality predictors have been studied, but none were proved reliable. Serum ferritin, an acute phase reactant and marker of hepatic necro-inflammation, is found to predict mortality in multiple liver diseases. We aimed to evaluate the role of serum ferritin and other clinical features, biochemical parameters and conventional scoring systems in predicting early mortality among ACLF.

Methods

A prospective cohort study was done from October 2017 to March 2019 at a tertiary care (non-transplant) center in eastern India. A total of consecutive 50 ACLF patients diagnosed, based on Asia Pacific Association for the Study of liver disease definition, were investigated for ferritin and other laboratory parameters on day-0, day-7, and followed up for 28 days.

Results

Although the majority did not have organ failure (ACLF grade 0) according to European Association for Study of Liver-chronic liver failure sequential organ failure assessment criteria, early mortality was high (56%). On undergoing univariate analysis, multiple variables (ascites, HE, creatinine, total leucocyte count (TLC), bilirubin, albumin) predicted mortality. However, on multivariate analysis, only total bilirubin independently predicted. None of the scores on day-0 were predictive, while model for end-stage liver disease [area under the receiver operating characteristics (AUROC)-0.703, 95% confidence interval [CI]: 0.535-0.859] and Child-Turcotte-Pugh (AUROC-0.697, 95% CI: 0.550-0.855) on day-7 did.

Conclusion

ACLF is a dynamic process; day-7 assessment with above predictors, to be considered a milestone for prognostication and opting treatment modalities. Serum ferritin does not predict early mortality in ACLF.

Need for hepatitis A prevention in patients with chronic liver disease in the changing epidemiological setting of India

The burden of chronic liver disease (CLD) in India is high, particularly among middle-aged men, with nearly 220,000 deaths due to cirrhosis in 2017. CLD increases the risk of infection, severe disease (e.g. hepatitis A virus or HAV superinfection, acute-on-chronic liver failure, fulminant hepatic failure), and mortality. Hence, various countries recommend HAV vaccination for CLD patients. While historic Indian studies showed high seroprevalences of protective HAV antibodies among Indian adults with CLD, the most recent ones found that nearly 7% of CLD patients were susceptible to HAV infection. Studies in healthy individuals have shown that HAV infection in childhood is decreasing in India, resulting in an increasing population of adults susceptible to HAV infection. As patients with CLD are at increased risk of severe HAV infection, now may be the time to recommend HAV vaccination among people with CLD in India.

World Gastroenterology Organisation classification and a new type-based prognostic model for hepatitis B virus-related acute-on-chronic liver failure

BACKGROUND

The acute-on-chronic liver failure (ACLF) classification, proposed by the World Gastroenterology Organisation (WGO), attempts to cover all ACLF patients diagnosed in the East and West. This study aimed to explore and establish a prognostic model based on this classification.

METHODS

A total of 1159 hepatitis B virus-ACLF patients, enrolled with 90-day follow-up data, were divided into three groups (type A, B, and C) according to WGO ACLF classification and analyzed. A model of ACLF prognosis based on type (MAPT) was developed in a derivation cohort (n = 566); its reproducibility was tested in a validation cohort (n = 593).

RESULTS

A significant difference in 90-day mortality among the three groups was observed (31.1%, type A; 40.9%, type B; 61.4%, type C, P < 0.001). ACLF type was determined to be an independent risk factor of 90-day mortality in HBV-ACLF patients. An MAPT, inclusive of type and five other variables, was built and validated; it was found to be superior to the Chronic Liver Failure (CLIF) Consortium ACLF score, Model for End-Stage Liver Disease, CLIF-Sequential Organ Failure, and Child-Turcotte-Pugh scores in predicting 90-day mortality, with an area under the receiver operating characteristic curve of 0.802 (95% CI [0.763-0.836]), sensitivity of 71.77%, and specificity of 75.82%.

CONCLUSIONS

The MAPT model showed excellent predictive value for 90-day mortality in HBV-ACLF and can likely expand the clinical application of WGO ACLF classification.

A Study on the Temporal Trends in the Etiology of Cirrhosis of Liver in Coastal Eastern Odisha

Background

The etiology of cirrhosis of liver is known to change with time due to various factors including awareness, preventive interventions, and lifestyle changes in society. However, there is scarce Indian data available about temporal trends in etiology of cirrhosis of liver. Hence, the aim of this study was to study the temporal trends in the etiology of cirrhosis of liver.

Materials and methods

This is a retrospective study conducted in the Department of Gastroenterology, Srirama Chandra Bhanja Medical College and Hospital, Cuttack, from January 2005 to December 2017. Data were collected from hospital records of all patients admitted to the Gastroenterology unit. A Poisson regression model was used to compare the hospitalization rate for different etiologies of cirrhosis of liver. All data were analyzed using Stata version 5.1 software.

Results

A total of 4,331 hospitalized patients of cirrhosis of liver were included in the analysis, of whom 2,742 (63.3%) had alcohol-related cirrhosis, 858 (19.8%) had viral hepatitis-related cirrhosis, and 731 (16.9%) had cirrhosis of liver due to nonalcohol and nonviral causes. The proportion of alcohol-related cirrhosis was increased by 26% from 2005 to 2017 (RR 1.26, p for trend <0.001). Though there were minimal ups and downs observed in the admission rate of viral hepatitis-related liver cirrhosis during later years, this was remarkably reduced by 73% (RR 0.27, p for trend <0.001) in the year 2017 at the end of the study. Similarly, the proportion of cirrhosis due to nonalcohol and nonviral causes decreased by 26% (RR 0.74, p for trend <0.001) by 2017.

Conclusion

Alcohol is the most common cause of cirrhosis of liver and the burden of alcohol-related cirrhosis is significantly increasing in comparison to other causes including viral infection, nonalcoholic steatohepatitis (NASH), and autoimmune hepatitis.

How to cite this article

Mishra D, Dash KR, Khatua C, et al. A Study on the Temporal Trends in the Etiology of Cirrhosis of Liver in Coastal Eastern Odisha. Euroasian J Hepato-Gastroenterol 2020;10(1):1–6.

Role of Granulocyte Colony Stimulating Factor on the Short-Term Outcome of Children with Acute on Chronic Liver Failure

BACKGROUND

Acute-on-chronic liver failure (ACLF) results in very high mortality in children. We aimed to evaluate the role of granulocyte colony-stimulating factor (GCSF) on short-term outcome of children with ACLF in a nontransplant unit.

METHODS

Children (aged > 1 year) diagnosed with ACLF over a 15 month period were randomised. Group A was given GCSF therapy along with standard medical care (SMC - details in supplementary data) and group B was given only SMC. The outcome was evaluated as survival at 30 and 60 days of therapy.

RESULT

Thirty-one children with ACLF were enrolled, with a mean age of 6.92 ± 4.3yrs. A total of 15 patients were randomised to group A and 16 to group B. The overall mortality was 54.83%. The intervention group showed survival rates of 80%, 66.67% and 53.3%, whereas the control group had survival rates of 43.75%, 37.5% and 37.5% at 14, 30 and 60 days, respectively. A significant survival benefit was noted on day 14 (p = 0.043) of therapy in group A with significant difference in Child-Turcotte-Pugh (CTP) and pediatric end-stage liver disease (PELD) scores in the two groups. After an initial rise in group A, the granulocyte counts fell to become comparable in the two groups by day 30 and 60, indicating that the effect of GCSF therapy wears off over time. There was no significant difference in the overall survival, median/mean CTP, PELD and MCS (Modified Cliff sequential organ failure assesment (SOFA)) scores on day 30 and 60. Mean (%) CD 34 + cells level showed a rise on day 7 in group A but was statistically insignificant.

CONCLUSION

The present study shows that GCSF therapy at 5 mcg/kg/day for 5 days seems to be ineffective in improving the survival outcome on day 30 and 60 of therapy. Studies with larger number of children enrolled and longer duration of therapy are required. (CTRI/2017/11/010420).

Clinical Presentation and Mortality Determinants of Alcohol-Related Liver Disease: A Single-Center Experience of the Rising Menace from Eastern India

Objectives

Recently, the incidence of alcohol-related liver disease has been rising alarmingly in India with late presentation and short survival. Better delineation of factors affecting mortality is needed for optimal utilization of constrained resources like liver transplantation.

Methods

Baseline data of 395 patients with alcohol-related liver disease including age, clinical presentation, alcohol parameters (amount, duration, type), laboratory parameters for detecting organ failure, and prognostic scores were compared between survivor and deceased groups. Further subgroup analysis of deceased patients was done to identify factors associated with early mortality in acute-on-chronic liver failure (ACLF) and cirrhosis groups by multivariate analysis and receiver operating characteristic (ROC) curves. Only best supportive medical therapy was offered to all.

Results

80 (20.3%) patients had alcoholic hepatitis (without cirrhosis) and recovered completely with abstinence. 315 (79.7%) had evidence of either cirrhosis (n = 182, 46.1%) or ACLF (n = 133, 33.6%) at presentation and all died within the next 2 years of follow-up, earlier in the ACLF cases. All deceased patients had been heavy drinkers for long periods (>85 g/day for >17 years). Higher age, amount of alcohol consumption, number of organ failures and discriminant function score predicted severe disease and early mortality, the latter being the best predictor. The European Foundation for the study of chronic liver failure consortium (CLIF-C) score has good applicability in Indian ACLF cohorts. Serum glutamic pyruvic transaminase was normal in 73.8% of deceased patients compared to only 12.5% of survivors. Abstinence did not result in complete normalization of deranged laboratory parameters in those who died.

Conclusion

Alcohol-related liver disease is serious with high short-term mortality, which has early identifiable but mostly irreversible factors. Urgent measures need to be taken to curb this rising menace.

Acute-on-Chronic Liver Failure: Etiology of Chronic and Acute Precipitating Factors and Their Effect on Mortality

BACKGROUND

The present study is planned to assess etiologies, course, and outcome in patients with acute-on-chronic liver failure (ACLF).

METHODS

Two hundred and eight (182 males and 26 females) patients of ACLF fulfilling modified Asia Pacific Association For Study Of Liver Consensus criteria 2009 admitted to the gastroenterology department of SMS Medical College and hospital, Jaipur, between October 2015 and December 2017 were included. We evaluated etiology of underlying chronic disease and the acute event precipitating decompensation in ACLF.

RESULTS

Most common etiology of chronic liver disease (CLD) was alcohol with 133 (63.94 %) patients. Viral hepatitis, cryptogenic cirrhosis, autoimmunity, nonalcoholic steatohepatitis, and Wilson disease as causes of CLD were present in 32 (15.4%), 29 (13.94%), 9 (4.3%), 3 (1.4%), and 2 (1%) cases, respectively. Alcohol, sepsis, bleeding, reactivation of hepatitis B, hepatitis E, antitubercular drugs, and autoimmune hepatitis as the causes of acute event were present in 100 (48.08%), 34 (16.35%), 19 (9.1%), 17 (8.2 %), 15 (7.2%), 13 (6.25%), and 2 (0.96%) patients, respectively. In 8 (3.85%) patients, the precipitating event could not be known. Mortality (in-hospital) in this study was 37.5%. Higher model for end-stage liver disease score and high Child-Turcotte-Pugh score score were significantly associated with mortality (P <0.001). Patients with higher ACLF grade were associated with higher mortality. Alcohol as a cause of CLD was significantly associated with mortality (p=0.0146, 95% confidence interval between 3.802 and 30.979). There was no significant difference regarding acute precipitating events between survivors and nonsurvivors.

CONCLUSIONS

Alcohol was the most common cause for chronic etiology as well as acute precipitating event. Alcohol as a cause of CLD was significantly associated with mortality.

Safety and efficacy of antibiotics among acutely decompensated cirrhosis patients

BACKGROUND AND AIM

Infection is a leading precipitant of acute-on-chronic liver failure. This study aims to determine the safety and efficacy of antibiotics within acute-on-chronic liver failure.

METHODS

Retrospective study of 457 acute-on-chronic liver failure patients admitted to the University of Arizona Health Network between January 1 and December 31, 2014. Eligibility criteria were as follows: at least 18 years of age and 6 months follow-up, data available to calculate systemic inflammatory response syndrome (SIRS), and acute-on-chronic liver failure. This study collected patient's clinical features and historical data. Key data points were infection, antibiotic use, and SIRS. This study used Cox proportional hazards to model the effects of clinical factors on risk of death.

RESULTS

A total of 521 of 1243 met the inclusion criteria, and 64 had missing data, leaving 457 patients. Infection resulted in higher hazard (hazard ratio [HR] = 1.6, confidence interval [CI]: 1.1-1.3, P = 0.01). Patients with infections and antibiotics, compared with non-infected patients without antibiotics, had higher hazard (HR = 1.633, CI: 1.022-2.609, P = .04). Of those infected patients with antibiotics, SIRS patients experienced higher hazard (HR = 1.9, CI: 1.1-3.0, P = .007). Multivariable Cox proportional hazards associated the following with higher hazard: SIRS (HR = 1.866, CI: 1.242-2.804, P = 0.003), vancomycin (HR = 1.640, CI: 1.119-2.405, P = 0.011), Model for End-Stage Liver Disease (HR = 1.051, CI: 1.030-1.073, P < 0.001), gastrointestinal bleeding (HR = 1.727, CI: 1.180-2.527, P = 0.005), and hepatic encephalopathy (HR = 1.807, CI: 1.247-2.618, P = 0.002).

CONCLUSION

Overall, treatment of infection with antibiotics did not improve survival; however, patients not meeting SIRS criteria had better outcomes, and vancomycin was associated with poorer survival among acute-on-chronic liver failure patients.

Acute on Chronic Liver Failure-In-Hospital Predictors of Mortality in ICU

AIMS

We studied in-hospital predictors of mortality of acute on chronic liver failure (ACLF) in Indian patients.

METHODS

Patients admitted to the intensive care unit of our institute fulfilling the definition of ACLF based on the Asia-Pacific Association for Study of Liver Disease (APASL) consensus were included. Complete history and medical evaluation to assess the etiology of underlying liver cirrhosis and to identify the acute precipitating insult of worsening liver function was done. Data was prospectively recorded and various scoring systems and individual clinical and laboratory parameters were assessed to identify predictors of 28 days mortality.

RESULTS

64 out of 240 patients screened for ACLF were analyszed in the study. Median age was 44 years and 53% were males. Alcohol was the primary cause of cirrhosis in 60.93%. Infections and active alcoholism was the main precipitating acute insult in 43% and 37% patients respectively. 28% patients had history of ingestion of hepato-toxic drugs as the acute insult. More than one acute insult was seen in 37.5% patients and type-II hepatic injury was the most common type. 28 days in hospital mortality was 43.75% and was highest in patients with sepsis (67.8%). Presence of hepato-renal syndrome and need for ventilation was associated with poor outcome. Though multiple variables were significant in predicting mortality on univariate analysis, yet on regression model only APACHE II and shock could significantly predict mortality with odds ratio of 3.18 and 9.14 respectively. Highest mortality was seen with cerebral and lung as organ failure and mortality increased as the number of organ failure worsened. CLIF-SOFA and APACHE-II scores having area under curve > 0.8 had higher ability to predict mortality.

CONCLUSION

ACLF carries high short-term mortality and early intervention by liver transplantation should be considered in patients who shows high risk of mortality.

Acute-on-chronic liver failure in a multi-ethnic Asian city: A comparison of patients identified by Asia-Pacific Association for the Study of the Liver and European Association for the Study of the Liver definitions

AIM

To explore the applicability of the Asia-Pacific Association for the Study of the Liver (APASL) and European Association for the Study of the Liver (EASL) guidelines for acute-on-chronic liver failure (ACLF) in profiling patients and determining the outcome.

METHODS

Patients admitted to a tertiary hospital in Singapore with acute decompensation of liver disease from January 2004 to July 2014 are screened for ACLF according to the APASL and EASL criteria. The patients’ data (including basic demographics, information about existing chronic liver disease, information about the acute decompensation, relevant laboratory values during admission, treatment, and outcome) are retrospectively analyzed to determine the background, precipitating factors and outcome.

RESULTS

A total of 458 liver patients is analyzed, and 78 patients with ACLF are identified. Sixty-three patients (80.8%) meet the APASL criteria, 64 patients (82.1%) meet the EASL criteria, and 49 patients (62.8%) fulfilled both criteria. The most common causes of acute liver injury are bacterial infections (59.0%), hepatitis B flare (29.5%), and variceal bleeding (24.4%). The common aetiologies of the underlying chronic disease included hepatitis B (43.6%), alcoholic (20.5%) and cryptogenic (11.5%) liver disease. The overall mortality rate is 61.5%. Increased age, the number of organ failures (as per CLIF-SOFA score), peak creatinine, INR, and amylase levels are associated with increased mortality or the need for liver transplantation. 14.3% of patients undergo liver transplantation with a 100% 1-year survival rate.

CONCLUSION

Both APASL and EASL criteria have identified ACLF patients with high three-month mortality, but those who fulfill APASL criteria alone have a better survival.

Toward a Better Definition of Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) has been defined differently in the East and West. The definitions given by Asian Pacific association for the study of liver (APASL) and American association for the study of liver (AASLD) and European association for the study of liver (EASL) working group have fundamental deficiencies and contradictions and do not encompass all patients with ACLF seen in the East and West. Although the World Gastroenterology Organisation (WGO) working party attempted to provide an improved definition but this too is not appropriate. In this article, we have compared the various definitions of ACLF given by APASL, EASL-AASLD and WGO and suggest a comprehensive definition for prospective collection of data on ACLF.

Liver Transplantation for Acute on Chronic Liver Failure

BACKGROUND

Acute-on chronic liver failure (ACLF) is defined as acute insult on previous liver disease that causes sudden worsening of liver functions.

METHODS

ACLF is characterized by high incidence of organ failure and prognosis is remarkably worse than patients with cirrhosis. Incidence of organ failures is very high despite best medical care and timely liver transplant before development of multi organ failure is associated with good survival rates.

RESULTS

At present, there are no reliable score or ways to correctly identify patients who are going to recover from patients who will need transplantation. Organ failures are important part of prognosis and to define need or futility of early liver transplantation.

CONCLUSION

Asian Pacific Association for the Study of the Liver (APASL) published their recommendations regarding ACLF in 2014. Several important studies regarding course/nature of disease and transplantation for ACLF became available after 2014 APASL recommendations and still there are some unanswered areas. The current review discusses various issues regarding liver transplantation in patients with ACLF.

Acute-on-chronic liver failure in India: The Indian National Association for Study of the Liver consortium experience

BACKGROUND AND AIM

The aim of this study was to analyze etiologies and frequency of hepatic and extrahepatic organ failures (OFs) and outcome of acute-on-chronic liver failure (ACLF) at 10 tertiary centers in India.

METHODS

In this retrospective study (2011-2014), patients satisfying Asian Pacific Association for the Study of the Liver definition of ACLF were included. Etiology of acute precipitating insult and chronic liver disease and outcomes were assessed. Occurrence and severity of OF were assessed by chronic liver failure-sequential organ failure assessment score.

RESULTS

The mean (±SD) age of 1049 consecutive ACLF patients was 44.7 ± 12.2 years; Eighty-two percent were men. Etiology of acute precipitants included alcohol 35.7%, hepatitis viruses (hepatitis A, hepatitis B, and hepatitis E) 21.4%, sepsis 16.6%, variceal bleeding 8.4%, drugs 5.7%, and cryptogenic 9.9%. Among causes of chronic liver disease, alcohol was commonest 56.7%, followed by cryptogenic and hepatitis viruses. Predictors of survival were analyzed for a subset of 381 ACLF patients; OF's liver, renal, coagulation, cerebral, respiratory, and failure were seen in 68%, 32%, 31.5%, 22.6%, 14.5%, and 15%, respectively. Fifty-seven patients had no OF, whereas 1, 2, 3, 4, and 5 OFs were recorded in 126, 86, 72, 28, and 12 patients, respectively. The mortality increased progressively with increasing number of OFs (12.3% with no OF, 83.3% with five OFs). During a median hospital stay of 8 days, 42.6% (447/1049) of patients died. On multivariate analysis by Cox proportional hazard model, elevated serum creatinine (hazard ratio [HR] 1.176), advanced hepatic encephalopathy (HR 2.698), and requirement of ventilator support (HR 2.484) were independent predictors of mortality.

CONCLUSIONS

Alcohol was the commonest etiology of ACLF. Within a mean hospital stay of 8 days, 42% patients died. OFs independently predicted survival.