Liver transplantation for patients with acute-on-chronic liver failure (ACLF) in Europe: Results of the ELITA/EF-CLIF collaborative study (ECLIS)

Indian National Association for the Study of Liver (INASL) Guidance Statements for Determining Futility in Liver Transplantation

Liver transplantation (LT) is a life-saving procedure for patients with end-stage liver disease; however, with the growing shortage of organ donors, the need to identify futile transplants has become increasingly urgent. Futility in liver transplantation refers to situations where the expected post-transplant survival or quality of life is poor, making the procedure unlikely to yield a meaningful benefit. Various definitions of futility are used across different countries and transplant centers, with criteria often based on clinical factors such as age, comorbidities, MELD score, and functional status. For hepatologists and transplant surgeons, clearer guidelines are essential to make informed decisions and avoid unnecessary transplants that may place patients at risk without improving their prognosis. While some studies have proposed futility scores, there is currently no universal consensus on a standardized definition or set of criteria. This highlights the need for further prospective trials to evaluate the predictors of futility in liver transplantation, aiming to refine decision-making processes, optimize organ allocation, and improve patient outcomes. Future research should focus on the development of universally accepted futility criteria and explore interventions to mitigate the factors contributing to transplant futility.

Stratifying risk in ACLF-3 patients: The impact of circulatory and respiratory failure on one-year post-transplant outcomes

BACKGROUND

In patients with Acute-on-Chronic Liver Failure grade 3 (ACLF-3), the number of organ failures (OF) before liver transplant (LT) is associated with poorer outcomes following LT. We hypothesized that ACLF-3 patients with circulatory and/or respiratory failure before LT would experience worse prognosis after LT.

METHODS

We analyzed ACLF-3 patients from the U.S. Scientific Registry of Transplant Recipients, categorized by OF combinations at the time of LT: 1) circulatory failure with other non-respiratory OF, 2) both circulatory and respiratory failures with other OF, 3) all other OF combinations excluding (1) and (2). Cox regression models assessed one-year mortality, and logistic regression examined one-year functional status.

RESULTS

Of 5054 ACLF-3 patients, 14 %(728/5054) died within one-year post-LT. The distribution was: 427 patients had circulatory failure with other OF, 1042 had circulatory and respiratory failure with other OF, and 3357 had all other possible combinations of OFs. Patients with both circulatory and respiratory failures experienced higher post-LT mortality than those with circulatory failure plus other OF (one-year Hazard Ratio (HR) for death: 1.32, 95 %CI: 1.08-1.62, p < 0.01). No differences were found between those with circulatory failure plus other OF and those with OF other than circulatory or respiratory. Patients with OF other than circulatory and respiratory failures had better one-year functional status compared to those with circulatory OF (OR for poor functional status: 0.73, 95 %CI: 0.54-0.98, p < 0.01).

CONCLUSION

Specific OF combinations affect post-LT outcomes in ACLF-3 patients. Combined respiratory and circulatory failure at LT time was associated with poorer outcomes, regardless of the number of OF.

The Association of Age and Liver Transplant Outcomes in Patients With Acute-On-Chronic Liver Failure

INTRODUCTION

To explore the role of age at listing on outcomes for patients with acute-on-chronic liver failure (ACLF) awaiting liver transplantation (LT).

MATERIALS AND METHODS

We assessed adult candidates listed for LT in the Scientific Registry of Transplant Recipients database from January 1, 2007 to June 30, 2018. Patients were divided into four groups based on age at listing: I (≤34), II (35-49), III (50-64), and IV (≥65). The ACLF grade was estimated (est-ACLF), and intent-to-treat survival, overall survival (OS), as well as potential predictors for OS was evaluated.

RESULTS

Est-ACLF-3 was associated with a higher 30-d cumulative dropout rate and inferior intent-to-treat survival across age groups. No difference was observed in OS among ACLF grades in group I, but significantly inferior OS was observed in higher ACLF grades in groups II-IV. Multivariate analysis showed age (P < 0.001, ref. group I; hazard ratio 0.995 for group II, P = 0.936; 1.196 for group III, P = 0.002; 1.651 for group IV, P < 0.001) and est-ACLF grade (P < 0.001, ref. est-ACLF-0; 1.214 for est-ACLF-1, P < 0.001; 1.246 for est-ACLF-2, P < 0.001; 1.578 for est-ACLF-3, P < 0.001) were independent predictors for OS. Generalized additive model showed different association between age and OS among different ACLF grades.

CONCLUSIONS

Young patients with high ACLF grades could achieve similar OS compared with those with low grades. Elderly patients with higher ACLF grades were associated with inferior outcomes after LT.

Contrast-enhanced ultrasound appearance of adrenal hemorrhage after orthotopic liver transplantation: a retrospective study

OBJECTIVES

This study aimed to identify the incidence of adrenal hemorrhage (AH) after OLT and to summarize the ultrasound (US) and contrast-enhanced ultrasound (CEUS) characteristics.

METHODS

Patients with adrenal lesions after OLT at our hospital were retrospectively reviewed between January 2010 and November 2023. The reference diagnosis was defined on the basis of surgical data, computed tomography scans, and magnetic resonance imaging with at least 12 months of follow-up. The incidence of AH and the US and CEUS characteristics after OLT were analyzed and compared with those of adrenal metastases.

RESULTS

A total of 23 patients (1.2%) with AH and 7 patients (0.35%) with suprarenal metastases were assessed. Compared with metastases, hematomas had more inhomogeneous echotextures (57% vs. 0.00%, P = 0.010), hypoechoic or mixed-echoic patterns (96% vs. 71%, P = 0.022), and anechoic areas (52% vs. 0.00%, P = 0.024), and their echotextures varied more over time (65% vs. 0.14%, P = 0.031). CEUS was performed on 12 patients with AH and 2 patients with metastases. A "jet-like" contrast superflux was observed in one actively bleeding hematoma, whereas no enhancement was observed in any static hematoma (100%). However, adrenal metastases had a contrast-enhanced appearance in the early arterial phase, followed by fast washout in the late phase (100%), and the difference was statistically significant (P < 0.001).

CONCLUSION

The sonographic characteristics of AH after OLT vary over time. CEUS is recommended when adrenal lesions are detected, as CEUS can differentiate AH from metastases.

Artificial Liver Support System Improves One-Year Prognosis of Patients With Hepatitis B Virus-Associated Acute-on-Chronic Liver Failure

BACKGROUND & AIMS

Acute-on-chronic liver failure (ACLF) is a complex syndrome with limited treatment options. This study aims to investigate the impact of artificial liver support system (ALSS) on the one-year prognosis of patients with Hepatitis B virus (HBV)-associated ACLF.

METHOD

A retrospective study was conducted on 239 patients with HBV-ACLF in Nanfang Hospital from January 2016 to June 2021. Patients were divided into the ALSS group (n = 103) and the Standard Medical Therapy (SMT group, n = 136). Demographic, clinical, and laboratory data were collected before the first ALSS treatment for patients in ALSS group, while baseline data were collected in SMT group. According to receiving different ALSS modes, patients in ALSS group were divided into plasma exchange (PE) group and non-PE group.

RESULT

The 12-week and 1-year liver transplant (LT) free survival rates in the ALSS group were significantly higher than that in the SMT group (65.05% vs 52.21%, p = 0.0011; 63.11% vs. 48.53%, p = 0.0006). ALSS therapy was the independent predictive factors associated with 12-week and 1-year mortality (hazard ratio, HR: 0.59, p = 0.04, and HR: 0.54, p = 0.01). Comparatively more ALSS-related complications were observed in PE group. After Propensity Score Matching, the 12-week and 1-year LT-free survival rates between PE and non-PE group were similar (88% vs. 80%, p = 0.227, 88% vs. 80%, p = 0.227).

CONCLUSION

ALSS therapy is a safe and effective treatment for HBV-ACLF. ALSS improves 1-year prognosis of patients with HBV-ACLF.

The Kidney and Extracorporeal Therapies in Acute-on-Chronic Liver Failure: What the Nephrologist Needs to Know

In this review, we discuss the pathophysiology and management of acute kidney injury (AKI) in the setting of acute-on-chronic liver failure (ACLF). ACLF is characterised by the occurrence of acute hepatic and/or extrahepatic organ failure, induced by immune dysregulation and systemic inflammation in patients with chronic liver disease. Kidney involvement is common, with AKI occurring in 30% to > 95% of ACLF patients, depending on the definition used. Since there is a lack of kidney biopsy data in these patients, the underlying pathophysiological basis of AKI remains incompletely understood, and systemic inflammation is believed to be the primary driver of organ injury. The management of AKI has been largely extrapolated from studies in decompensated cirrhosis, and there is little data specifically in the ACLF setting. However, available evidence suggests that structural kidney injury is more common in ACLF than in decompensated CLD, and therefore, AKI in ACLF is less likely to respond to volume repletion and vasopressors. Treatment options remain limited for those who are non-responsive to intravenous fluids and vasopressors. Liver transplantation (LT), with or without kidney transplantation, is the definitive treatment for these patients. At present, extracorporeal therapies such as therapeutic plasma exchange and kidney replacement therapies play a supportive role in ACLF as a bridge to LT; however, the optimal timing and dosing remain unclear. While theoretically, extracorporeal therapies have the potential to reverse or halt progression of organ damage in ACLF, there is limited evidence currently.

Liver transplantation improves prognosis across all grades of acute-on-chronic liver failure patients: A systematic review and meta-analysis

BACKGROUND

Liver transplantation (LT) is recognized as an effective approach that offers survival benefits for patients with acute-on-chronic liver failure (ACLF). However, controversies remain regarding the LT selection criteria, and meta-analyses reporting overall survival outcomes across different ACLF severity grades are lacking.

AIM

To depict a comprehensive postoperative picture of patients with ACLF of varying severity and contribute to updating LT selection.

METHODS

Systematic searches in Web of Science, EMBASE, PubMed, and Cochrane databases were performed, from inception to December 26, 2023, for studies exploring post-transplant outcomes among ACLF patients, stratified by severity grades as identified by the European Association for the Study of the Liver-Chronic Liver Failure criteria. The primary outcome of interest was the survival rate within one year, with post-transplant complications as secondary outcomes. Additionally, the subgroup analysis examined region-specific one-year survival rates.

RESULTS

A total of 17 studies involving 28025 participants were included. Patients with ACLF-1 and ACLF-2 have favorable survival within one year, with survival rates reaching 87% [95% confidence interval (CI): 84%-91%] and 86% (95%CI: 81%-91%), respectively. Despite the relatively lower survival (73%, 95%CI: 66%-80%) and higher incidence of infection (48%, 95%CI: 29%-67%) observed in ACLF-3 patients, their survival exceeds that of those who do not undergo LT. Moreover, post-transplant survival was highest in North America across all ACLF grades.

CONCLUSION

LT can provide survival advantages for ACLF patients. To optimize the utilization of scarce donor organs and improve prognosis, comprehensive preoperative health evaluations are essential, especially for ACLF-3 patients.

Acute-on-Chronic Liver Failure: Steps Towards Consensus

Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by organ failure and high short-term mortality. Since its first definition in 2013, many international organizations have defined this syndrome and, till now, there has been no agreement regarding definitions and diagnostic criteria. Although the precise mechanism of ACLF is unknown, precipitant factors and the systemic inflammation response play a major role. Specific management of this high-mortality syndrome is still under development, but a general consensus in the diagnosis and management of ACLF is needed.

Extracorporeal liver support and liver transplantation for acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is defined by acute decompensation, organ failure and a high risk of short-term mortality. This condition is characterized by an overwhelming systemic inflammatory response. Despite treating the precipitating event, intensive monitoring and organ support, clinical deterioration can occur with very poor outcomes. During the last decades, several extracorporeal liver support systems have been developed to try to reduce ongoing liver injury and provide an improved environment for the liver to regenerate or as a bridging therapy until liver transplantation. Several clinical trials have been performed to evaluate the clinical efficacy of extracorporeal liver support systems, but no clear impact on survival has been proven. DIALIVE is a novel extracorporeal liver support device that has been built to specifically address the pathophysiological derangements responsible for the development of ACLF by replacing dysfunctional albumin and removing pathogen and damage-associated molecular patterns (PAMPs and DAMPs). In phase II clinical trial, DIALIVE appears to be safe, and it seems to be associated with a faster time to the resolution of ACLF compared with standard medical treatment. Even in patients with severe ACLF, liver transplantation saves lives and there is clear evidence of transplant benefit. Careful selection of patients is required to attain good results from liver transplantation, but many questions remain unanswered. In this review, we describe the current perspectives on the use of extracorporeal liver support and liver transplantation for ACLF patients.

Organ dysfunction and failure in liver disease

Acute-on-chronic liver failure (ACLF) is a complex syndrome defined by the existence of different organ failures (OFs) in patients with chronic liver disease, mainly cirrhosis. Several definitions have been proposed to define the syndrome, varying in the grade of the subjacent liver disease, the type of precipitants and the organs considered in the definition. Liver, coagulation, brain, kidney, circulatory and pulmonary are the six types of OFs proposed in the different classifications, with different prevalence worldwide. Irrespective of the definition used, patients who develop ACLF present a hyperactive immune system, profound haemodynamic disturbances and several metabolic alterations that finally lead to organ dysfunction. These disturbances are triggered by different factors such as bacterial infections, alcoholic hepatitis, gastrointestinal bleeding or hepatitis B virus flare, among others. Because patients with ACLF present high short-term mortality, a prompt recognition is needed to start treatment of the trigger event and specific organ support. Liver transplantation is also feasible in carefully selected patients and should be evaluated.

Mechanisms and treatment approaches for ACLF

Acute-on-chronic liver failure (ACLF) is a life-threatening syndrome characterized by decompensation of cirrhosis, severe systemic inflammation and organ failures. ACLF is frequently triggered by intra- and/or extrahepatic insults, such as bacterial infections, alcohol-related hepatitis or flares of hepatic viruses. The imbalance between systemic inflammation and immune tolerance causes organ failures through the following mechanisms: (i) direct damage of immune cells/mediators; (ii) worsening of circulatory dysfunction resulting in organ hypoperfusion and (iii) metabolic alterations with prioritization of energetic substrates for inflammation and peripheral organ 'energetic crisis'. Currently, the management of ACLF includes the support of organ failures, the identification and treatment of precipitating factors and expedited assessment for liver transplantation (LT). Early LT should be considered in patients with ACLF grade 3, who are unlikely to recover with the available treatments and have a mortality rate > 70% at 28 days. However, the selection of transplant candidates and their prioritization on the LT waiting list need standardization. Future challenges in the ACLF field include a better understanding of pathophysiological mechanisms leading to inflammation and organ failures, the development of specific treatments for the disease and personalized treatment approaches. Herein, we reviewed the current knowledge and future perspectives on mechanisms and treatment of ACLF.

Management of the acute on chronic liver failure in the intensive care unit

Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.

Association between lactate-to-albumin ratio and short-term prognosis of acute-on-chronic liver failure treated with artificial liver support system

BACKGROUND

The impact of lactate-to-albumin ratio (LAR) on the outcome of acute-on-chronic liver failure (ACLF) is scant.

AIMS

To investigate the relationship between LAR and short-term prognosis in patients with COSSH (Chinese Group on the Study of Severe Hepatitis B) ACLF.

METHODS

A retrospective cohort study was conducted in patients with COSSH ACLF treated with an artificial liver support system. Restricted cubic splines, linear regression models, and Cox regression models were used to investigate the relationships of LAR with disease severity and 28-day prognosis.

RESULTS

The 28-day transplant-free and overall survival rates in the 258 eligible patients were 76.4% and 82.2%, respectively. The LAR in 28-day transplant-free survivors was lower than that in transplant or death patients [0.74 (0.58-0.98) vs. 1.03 (0.79-1.35), P <  0.001]. The LAR was positively associated with disease severity, 28-day transplant-free survival [adjusted hazard ratio (HR) (95% confidence interval (CI)) for transplant or death: 2.18 (1.37-3.46), P =  0.001], and overall survival [adjusted HR (95% CI) for death: 2.14 (1.21-3.80), P =  0.009]. Compared with patients with LAR < 1.01, patients with LAR ≥ 1.01 had poor 28-day prognosis [all adjusted HR (95% CI) > 1, P  < 0.05]. Lactate was not a potential modifier of the relationship between LAR and short-term prognosis.

CONCLUSION

LAR was positively associated with disease severity and poor short-term prognosis in patients with COSSH ACLF.

Association between lactate-to-albumin ratio and all-cause mortality in critically ill cirrhotic patients with sepsis: a retrospective analysis of the MIMIC-IV database

BACKGROUND

The impact of lactate-to-albumin ratio (LAR) on mortality of critically ill cirrhotic patients with sepsis is scant.

METHODS

Critically ill cirrhotic patients with sepsis were obtained from the MIMIC-IV database (v3.0). Cox regression models alone and in combination with restricted cubic splines, generalized additive models and smoothed curve fitting were used to investigate the relationship between LAR and all-cause mortality.

RESULTS

A total of 1864 patients were included. The 30-day, 90-day, and 180-day all-cause mortality rates were 38.0%, 46.3%, and 49.5%, respectively. Higher LAR were significantly and nonlinearly associated with higher risks of 30-day, 90-day, and 180-day all-cause mortality (all adjusted HR = 1.17, P < 0.001). L-shaped associations between LAR and 30-day, 90-day, and 180-day all-cause mortality were observed, with an inflection point of 1.05 (P for log-likelihood ratio < 0.01). Compared with patients with LAR < 1.05, patients with LAR ≥ 1.05 had higher risks of 30-day, 90-day, and 180-day all-cause mortality (adjusted HR (95% CI): 1.48 (1.27-1.72), 1.44 (1.25-1.66), and 1.38 (1.21-1.57), respectively). No potential modifiers were found in the relationship between LAR and mortality.

CONCLUSIONS

LAR was positively and nonlinearly associated with all-cause mortality in critically ill cirrhotic patients with sepsis. Thus, it could be used as a prognostic biomarker.

Individual mHLA-DR trajectories in the ICU as predictors of early infections following liver transplantation: a prospective observational study

BACKGROUND

Infections are a leading cause of early mortality after liver transplantation (LT). Prior to transplantation, cirrhosis-associated immune dysfunction significantly increases the risk of infection. This study investigated the potential of immune monitoring, with a focus on monocytic HLA-DR (mHLA-DR) expression, as a predictor of post-LT complications.

METHODS

We conducted a prospective study on 130 patients awaiting LT at Lyon University Hospital to assess mHLA-DR expression, lymphocyte subsets, and T-cell function before and after LT. Multivariate analysis and K-means longitudinal clustering were performed to explore the relationships between immune trajectories and clinical outcomes.

RESULTS

Among the 99 patients who underwent LT, 35.4% experienced infections early post-LT. No difference in outcome was found regarding lymphocyte count or function. Delayed mHLA-DR recovery (Day 7 < 11,000 AB/C) and pre-LT MELD scores > 30 emerged as independent infection risk factors, with ORs of 12.1 [4.4-38.2], p < 0.0001 and 4.9 [1.4-18.4], p = 0.01, respectively. Patients with delayed mHLA-DR restoration also had reduced one-year survival (77.8% versus 98.3%, p = 0.003). K-means clustering revealed three distinct mHLA-DR recovery profiles, with the slowest recovery group showing the poorest outcomes.

CONCLUSIONS

Our findings highlight mHLA-DR as an early predictor of post-LT infections. Monitoring post-LT immune function through mHLA-DR expression could guide individualized management strategies to improve outcomes. Trial registration The study was registered in the ClinicalTrials.gov registry: NCT03995537, date: June 20, 2019.

Association between neutrophil percentage to albumin ratio and short term prognosis of acute on chronic liver failure treated with artificial liver support system

The impact of neutrophil percentage-to-albumin ratio (NPAR) on the outcome of acute-on-chronic liver failure (ACLF) is scant. A retrospective cohort study was conducted in patients with ACLF treated with artificial liver support system (ALSS). The ACLF was diagnosed according to the Chinese Group on the Study of Severe Hepatitis B-ACLF (COSSH ACLF) criteria. Disease severity was rated according to the COSSH ACLF score. Restricted cubic splines, linear or Cox regression models were used to investigate the relationships of baseline NPAR with disease severity and 90-day prognosis. The 90-day transplant-free and overall survival rates of 258 eligible patients were 58.5% and 66.3%, respectively. The NPAR in transplant-free survivors was lower than that in transplant or death patients (22.8 ± 4.4 vs. 25.3 ± 3.7, P < 0.001). NPAR was positively associated with COSSH ACLF score (adjusted β (95% CI) > 0, P < 0.001), transplant-free survival (adjusted HR (95% CI) for transplant or death: 1.07 (1.02-1.13), P = 0.007), and overall survival (adjusted HR (95% CI) for death: 1.09 (1.03-1.15), P = 0.003). Patients with NPAR ≥ 22.4 had poor 90-day prognosis compared to the rest (all adjusted HR (95% CI) > 1, P < 0.05). NPAR was positively associated with disease severity and poor short-term prognosis in patients with COSSH ACLF who underwent ALSS treatment. Thus, it could be used as a prognostic biomarker for COSSH ACLF.

Acute-on-chronic liver failure (ACLF): the ‘Kyoto Consensus’—steps from Asia

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the “APASL ACLF Research Consortium (AARC)” was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia–Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the ‘Golden Therapeutic Window’, the ‘transplant window’, and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The ‘Kyoto APASL Consensus’ presented below carries the final recommendations along with the relevant background information and areas requiring future studies.

Acute-on-chronic liver failure (ACLF): the 'Kyoto Consensus'-steps from Asia

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the "APASL ACLF Research Consortium (AARC)" was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia-Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the 'Golden Therapeutic Window', the 'transplant window', and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The 'Kyoto APASL Consensus' presented below carries the final recommendations along with the relevant background information and areas requiring future studies.

Sex disparities in acute-on-chronic liver failure: From admission to the intensive care unit to liver transplantation

Acute-on-chronic liver failure (ACLF) is a severe clinical syndrome characterized by acute liver decompensation in patients with chronic liver disease, marked by systemic inflammation and systemic organ failure. In this review, we discussed sex-related disparities in the incidence, prognosis, and access to liver transplantation (LT) for patients with ACLF, particularly during Intensive Care Unit (ICU) management. Some studies have suggested that ACLF is more prevalent among male patients admitted to the ICU, and they have higher mortality rates than females. Available prognostic scores, such as CLIF-C or TAM-score, lack sex-specific adjustments. Sarcopenia seems to enhance the accuracy of these scores though this is observed only in male individuals. LT is the only effective treatment for patients with ACLF grade 2-3 who do not respond to medical therapies. Sex-related disparities occur in both access to LT and post-transplant outcomes, although the influence of sex on the prevalence, clinical course, and listing for LT in ACLF remains largely undetermined. A sex-orientated analysis of ICU outcomes in ACLF would facilitate the development of sex-orientated management strategies, thereby improving patients' outcomes.

[Abdominal organ transplantation in multimorbid patients]

Patients with an indication for transplantation of abdominal organs often suffer from terminal organ failure with a relevant number of comorbidities. This can be complicated by acute and underlying disease-related events or age-related comorbidities. The diagnostic assignment of symptoms is difficult and the available treatment options have to be adapted. During the evaluation, the waiting time for suitable donor organs and immediately prior to surgery, the treatment team, consisting of the referring physician and the interdisciplinary transplantation team needs to decide whether the transplantation can be performed.

Safety and Efficacy of DPMAS in Patients With Acute-on-Chronic Liver Failure Based on Different Platelet Count Levels

To investigate the effect of different platelet (PLT) counts on the safety and efficacy of the double-plasma molecular absorption system (DPMAS) in patients with acute-on-chronic liver failure (ACLF). A total of 156 patients with ACLF receiving DPMAS were divided into the observed group (40 × 109/L ≤ PLT < 50 × 109/L) and the control group (PLT ≥ 50 × 109/L) according to PLT count level. The safety and efficacy indices of bleeding-related complications, PLT reduction rate, total bilirubin (TBIL) reduction rate, and 28-days survival rate after DPMAS were analyzed and compared between the two groups. The incidence of bleeding complications during and after DPMAS in the observed and control groups (14.3% vs. 14.9%, p = 0.922), the decline rate of PLT immediately and 24 h after treatment (0.13 vs. 0.11/0.05 vs. 0.09, p = 0.256/0.161), and the 28-days survival rate after treatment (76.2% vs. 75.4%, p = 0.923) were not significantly different. The thromboelastogram before DPMAS showed no significant difference in PLT function between the two groups (p > 0.05). Although the TBIL level of the two groups rebounded 24 h after treatment compared with immediately after treatment, it decreased significantly immediately and 24 h after treatment compared with pre-treatment levels (p < 0.05). There was no significant difference in the rate of decline of serum TBIL immediately after treatment and 24 h after treatment between the two groups (0.33 vs. 0.35/0.14 vs. 0.16, p = 0.193 and 0.653, respectively). DPMAS is safe and effective in patients with ACLF with 40 × 109/L ≤ PLT count < 50 × 109/L.

Robust Predictive Performance of the SALT-M Score for Clinical Outcomes in Asian Patients With Acute-on-Chronic Liver Failure

BACKGROUND

Acute-on-chronic liver failure (ACLF) is a syndrome of patients with chronic liver disease presenting with multiple organ failures. Recently, Sundaram-ACLF-LT Mortality (SALT-M) score has been developed to predict 1-year post-liver transplantation mortality. We validated the SALT-M score in a large-volume, Asian single-centre cohort.

AIMS

We validated the SALT-M score in a large-volume, Asian single-centre cohort.

METHODS

We analysed 224 patients of ACLF grade 2-3. Area under the receiver operating characteristic curve (AUROC) and concordance index (c-index) were used to assess and compare the predictability of posttransplant mortality of SALT-M and other scores. Moreover, we compared the survivals of patients with high and low SALT-M, in conjunction with MELD score and ACLF grade.

RESULTS

The AUROC for prediction of 1-year post-LT survival was higher in SALT-M (0.691) than in MELD, MELD-Na, MELD 3.0 and delta-MELD. Similarly, the c-index of the SALT-M (0.650) was higher than aforementioned MELD systems. When categorised by the cut-off of SALT-M ≥ 20 and MELD ≥ 30, patients with high SALT-M exhibited lower post-LT survival than those with low SALT-M scores regardless of high or low MELD (40.0% for high SALT-M/high MELD vs. 42.9% for high SALT-M/low MELD vs. 73.8% for low SALT-M/high MELD vs. 63.7% for low SALT-M/low MELD, p < 0.001). In patients with ACLF grade 3, SALT-M effectively stratified the posttransplant mortality (39.4% for high SALT-M vs. 63.1% for low SALT-M, p = 0.018).

CONCLUSIONS

SALT-M outperformed previous MELD systems for predicting posttransplant mortality in Asian LT cohort with severe ACLF. Transplantability for patients with severe ACLF could be determined based on SALT-M.

AKI in ACLF: navigating the complex therapeutic puzzle

INTRODUCTION

Acute kidney injury (AKI) in patients with acute-on-chronic liver failure (ACLF) is driven by the severity of systemic inflammation, acute portal hypertension driving circulatory dysfunction, hyperbilirubinemia, and toxicity of bile acids. The spectrum is mostly structural, associated with reduced response to vasoconstrictors. The progression is rapid, and need of renal replacement therapy and extracorporeal therapies may be required for the management. The development of renal failure is usually considered when defining the syndrome of ACLF.

AREAS COVERED

In the current review we discuss the pathophysiological basis, natural course, and response to the current therapeutic modalities and challenges in assessing and managing AKI in patients with ACLF. We conducted a comprehensive search of electronic databases such as PubMed, Web of Science, and Scopus using keywords like lactate, NGAL, and PHTN, as well as CRRT, PLEX, ACLF, and AKI phases for our review. Peer-reviewed English papers that addressed our issue were considered.

EXPERT OPINION

The difficulties and specific management strategies for AKI in ACLF patients are discussed emphasizing the importance of customized protocols, risk assessment guided by biomarkers, and investigation of extracorporeal therapies that target bile acids.

Long-term outcome following liver transplantation of patients with ACLF grade 3

BACKGROUND & AIMS

Utility, a major principle for allocation in the context of transplantation, is questioned in patients with acute-on-chronic liver failure grade 3 (ACLF-3) who undergo liver transplantation (LT). We aimed to explore long-term outcomes of patients included in a three-centre retrospective French study published in 2017.

METHOD

All patients with ACLF-3 (n = 73), as well as their transplanted matched controls with ACLF-2 (n = 145), 1 (n = 119) and no ACLF (n = 292), who participated in the Princeps study published in 2017 were included. We explored 5- and 10-year patient and graft survival rates, causes of death and their predictive factors.

RESULTS

Median follow-up of patients with ACLF-3 was 7.5 years. At LT, median MELD was 40. In patients with ACLF-3, 2, 1 and no ACLF, 5-year patient survival rates were 72.6% vs. 69.7% vs. 76.4% vs. 77.0%, respectively (p = 0.31). Ten-year patient survival for ACLF-3 was 56.8% and was not different to other groups (p = 0.37). Leading causes of death in patients with ACLF-3 were infections (33.3%) and cardiovascular events (23.3%). After exclusion of early death, UCLA futility risk score, age-adjusted Charlson comorbidity index and CLIF-C ACLF score were independently associated with 10-year patient survival. Long-term graft survival rates were not different across the groups. Clinical frailty scale and WHO performance status improved over time in patients alive after 5 years.

CONCLUSION

5- and 10-year patient and graft survival rates were not different in patients with ACLF-3 compared to matched controls. 5-year patient survival is higher than the 50%-70% threshold defining the utility of a liver graft. Efforts should focus on candidate selection based on comorbidities, as well as the prevention of infection and cardiovascular events.

IMPACT AND IMPLICATIONS

While short-term outcomes following liver transplantation in the most severely ill patients with cirrhosis (acute-on-chronic liver failure grade 3 [ACLF-3]) are known, long-term data are limited, raising questions about the utility of graft allocation in the context of scarce medical resources. This study provides a favourable long-term update, confirming no differences in 5- and 10-year patient and graft survival following liver transplantation in patients with ACLF-3 compared to matched patients with ACLF-2, ACLF-1, and no-ACLF. The study highlights the risk of dying from infection and cardiovascular causes in the long-term and identifies scores including comorbidity evaluation, such as the age-adjusted Charlson comorbidity index, as independently associated with long-term survival. Therefore, physicians should consider the cumulative burden of comorbidities when deciding whether to transplant these patients. Additionally, after transplantation, the study encourages mitigating infectious risk with tailored immunosuppressive regimens and tightly managing cardiovascular risk over time.

Benefits of liver transplant in critically ill patients with acute-on-chronic liver failure: Implementation of an urgent living-donor program

We evaluated the liver transplantation (LT) criteria in acute-on-chronic liver failure (ACLF), incorporating an urgent living-donor LT (LDLT) program. Critically ill patients with a Chronic Liver Failure Consortium (CLIF-C) ACLF score (CLIF-C_ACLF_score) ≥65, previously considered unsuitable for LT, were included to explore the excess mortality threshold of the CLIF-C_ACLF_score (CLIF-C_ACLF_score_threshold). We followed 854 consecutive patients with ACLF (276 ACLF grade 2 and 215 ACLF grade 3) over 10 years among 4432 LT recipients between 2008 and 2019. For advanced ACLF patients without immediate deceased-donor (DD) allocation, an urgent LDLT program was expedited. The CLIF-C_ACLF_score_threshold was determined by the metrics of transplant survival benefit: >60% 1-year and >50% 5-year survival rate. In predicting post-LT mortality, the CLIF-C_ACLF_score outperformed the (model for end-stage liver disease-sodium) MELD-Na and (model for end-stage liver disease) MELD-3.0 scores but was comparable to the Sundaram ACLF-LT-mortality score. A CLIF-C_ACLF_score ≥65 (n = 54) demonstrated posttransplant survival benefits, with 1-year and 5-year survival rates of 66.7% and 50.4% (P < .001), respectively. Novel CLIF-C_ACLF_score_threshold for 1-year and 5-year mortalities was 70 and 69, respectively. A CLIF-C_ACLF_score-based nomogram for predicting survival probabilities, integrating cardiovascular disease, diabetes, and donor type (LDLT vs DDLT), was generated. This study suggests reconsidering the criteria for unsuitable LT with a CLIF-C_ACLF_score ≥65. Implementing a timely salvage LT strategy, and incorporating urgent LDLT, can enhance survival rates.

EASL Clinical Practice Guidelines on liver transplantation

Liver transplantation (LT) is an established life-saving procedure. The field of LT has changed in the past 10 years from several perspectives, with the expansion of indications, transplantation of patients with acute-on-chronic liver failure, evolution of transplant oncology, the use of donations after cardiac death, new surgical techniques, and prioritisation of recipients on the waiting list. In addition, the advent of organ perfusion machines, the recognition of new forms of rejection, and the attention paid to the transition from paediatric to adult patients, have all improved the management of LT recipients. The purpose of the EASL guidelines presented here is not to cover all aspects of LT but to focus on developments since the previous EASL guidelines published in 2016.

Liver transplantation for critically ill patients with acute on chronic liver failure: a prospective national programme of waitlist prioritisation

Background

Acute on Chronic Liver Failure (ACLF) complicates chronic liver disease (CLD) combining rapidly progressive hepatic with extra-hepatic multiple organ failure and high short-term mortality. Effective therapeutic options are very limited, and liver transplantation (LT) seldom utilised through concerns of high recipient mortality and resource use. Retrospective reports suggest recent outcomes may have improved, but use of LT for ACLF has not been prospectively assessed.

Methods

A prospective programme of prioritised liver graft allocation for selected recipients with ACLF through registration on a new national tier, initiated in May 2021 in all 7 United Kingdom LT centres. Candidates were selected by centre multidisciplinary teams, with inclusion criteria mandating cirrhotic CLD with ACLF requiring critical care (CC) organ support and expected 1-month mortality >50%. Exclusion criteria included age ≥60 years, previous LT, comorbidity or substance misuse profile precluding elective LT. A pilot 50 registrations were planned, with pre-specified futility criteria of a 1-year post-LT survival of 60%.

Findings

Fifty-two patients were registered on the ACLF tier, median (IQR) age 46 (39-52) years, ACLF grade 3 (3-3) and Model for End-stage Liver Disease (MELD) 39 (35-40). At registration 32 (62%) required mechanical ventilation, 44 (85%) vasopressors and 46 (89%) renal replacement. Forty-two (81%) underwent LT 2 (2-5) days after registration: 10 (19%) did not. All non-transplanted died at median 7 (4-13) days after registration (p < 0.0001 vs. LT). Post-LT follow-up was 212 (119-530) days and patient survival 81% (95% CI 66-91): 28-, 90-day and 1-year survival after registration 93%, 86% and 77%. Median length of CC and hospital stay in LT recipients was 16 (8-28) and 35 (23-54) days respectively.

Interpretation

We report the first prospective national series of prioritised liver transplantation for critically ill patients with ACLF. For selected recipients LT is a practical and highly effective treatment option where no other similarly effective interventions exist.

Funding

There was no funding for the study.

Liver transplantation for acute liver failure and acute-on-chronic liver failure

Acute liver failure (ALF) and acute-on-chronic liver (ACLF) are distinct phenotypes of liver failure and, thus, need to be compared and contrasted for appropriate management. There has been a significant improvement in the outcomes of these patients undergoing liver transplantation (LT). Survival post-LT for ALF and ACLF ranges between 90% and 95% and 80% and 90% at 1 year, futility criteria have been described in both ALF and ACLF where organ failures define survival. Plasma exchange and continuous renal replacement therapy may serve as bridging therapies. Identifying the futility of LT is as necessary as the utility of LT in patients with ALF and ACLF. The role of regenerative therapies such as granulocyte colony-stimulating factors in ACLF and hepatocyte and xenotransplantation in both conditions remains uncertain. Measures to increase the donor pool through increasing deceased donor transplants in Asian countries, living donations in Western countries, auxiliary liver transplants, and ABO-incompatible liver transplants are necessary to improve the survival of these patients. In this review, we discuss the similarities and differences in clinical characteristics and the timing and outcomes of LT for ALF and ACLF, briefly highlighting the role of bridging therapies and providing an overview of recent advances in the management of ALF and ACLF.

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.

Common definitions and variables are needed for the United States to join the conversation on acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a variably defined syndrome characterized by acute decompensation of cirrhosis with organ failures. At least 13 different definitions and diagnostic criteria for ACLF have been proposed, and there is increasing recognition that patients with ACLF may face disadvantages in the current United States liver allocation system. There is a need, therefore, for more standardized data collection and consensus to improve study design and outcome assessment in ACLF. In this article, we discuss the current landscape of transplantation for patients with ACLF, strategies to optimize organ utility, and data opportunities based on emerging technologies to facilitate improved data collection.

Respiratory and physical therapy in the intensive care unit after liver transplantation for acute-on-chronic liver failure: a case report

Acute-on-chronic liver failure (ACLF) is a severe clinical condition for which liver transplantation (LT) is the only curative option. Due to the recipients' generally poor pre-operative clinical conditions and extensive surgery, post-LT respiratory disorders are very common and significantly contribute to related morbidity and mortality. We report the case of a 49-year-old patient with ACLF grade 3 who has been taken care of by the Respiratory Physiotherapy Team since hospital admission. After the extubation, the patient was supported with non-invasive ventilation and mechanical in-exsufflation; meanwhile, early resistance and functional training were started. No adverse events occurred during physiotherapy sessions, and the patient returned home without respiratory support. Respiratory and physical therapy in the intensive care unit after LT were safe and feasible interventions for this patient. Given the high incidence of postoperative pulmonary complications and the high rehabilitation needs, we suggest that physiotherapy should be provided for ACLF recipients.

Frailty and sarcopenia in patients with acute-on-chronic liver failure: Assessment and risk in the liver transplant setting

Frailty and sarcopenia are well-recognized factors related to worse outcomes in patients with cirrhosis, including liver transplant (LT) candidates. Implications of pre-LT functional and muscle deterioration also affect post-LT outcomes. Patients with cirrhosis and acute-on-chronic liver failure (ACLF) have a lower survival rate, both before and after LT. There is a need to better identify those patients with ACLF who would benefit from LT. This review aims to present the available data about frailty and sarcopenia in patients with ACLF in the LT setting. An exhaustive review of the published literature was conducted. Data regarding frailty and sarcopenia in LT candidates with ACLF are scarce and heterogeneous. Studies evaluating frailty and sarcopenia in critically ill patients outside the liver literature are also presented in this review to enrich the knowledge of this field in expansion. Frailty and sarcopenia seem to contribute to worse outcomes in LT candidates with ACLF, both before and after LT. Sarcopenia evaluation may be the most prudent approach for those very sick patients. Skeletal muscle index assessed by computed tomography is recommended to evaluate sarcopenia. The role of muscle ultrasound and bioelectrical impedance analysis is to be determined. Frailty and sarcopenia are crucial factors to consider on a case-by-case basis in LT candidates with ACLF to improve patient outcomes.

Patient Selection for Living Donor Liver Transplantation in Acute-on-chronic Liver Failure

BACKGROUND AND OBJECTIVES

Acute-on-chronic liver failure (ACLF) is associated with high short-term mortality without liver transplantation (LT). The selection criteria for LT in these patients are not well defined. The objective of this study was to determine factors associated with post-transplant survival in ACLF.

METHODS

This was a single-center retrospective study of patients who underwent living donor liver transplantation (LDLT) for ACLF between 2012 and 2022. Out of 1093 transplants, 110 patients had underlying ACLF, based on the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria. We looked at factors associated with 1-year posttransplant survival.

RESULTS

The median model for end-stage liver disease (MELD) score was 33.5 (31-38), and the 1-year posttransplant survival was 72%. Six risk factors were associated with posttransplant survival, namely, body mass index > 30 kg/m2 [HR, 4.4; 95% CI, 1.8-10.7], platelet count < 66,000/μl [HR, 2.91; CI,1.2-6.6], poor response to medical treatment [HR, 2.6; CI, 1.1-5.7], drug-resistant bacterial or fungal cultures [HR, 4.2; CI, 1.4-12.4], serum creatinine > 2.5 mg/dl [HR, 3.4; CI, 1.5-7.7], and graft-to-recipient weight ratio < 0.7 [HR, 4.8; CI, 1.4-16.3]. The 1-year post-transplant survival was 84% in patients with 0-2 risk factors (n = 89) and was 6% with 3 risk factors (n = 15) (P < 0.001). For 1-year posttransplant survival, the area under curve (AUC) for the current model was 0.8 (0.69-0.9). The AUC for CLIF-ACLF, Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), and EASL-CLIF ACLF grades was < 0.5.

CONCLUSION

In LT for ACLF, acceptable survival can be achieved when less than three high-risk factors are present.

Infections in cirrhosis

Cirrhosis is an immune dysfunction state, and as such, patients with cirrhosis are susceptible to bacterial, fungal, and viral infections. Because of infection, these patients have a propensity to develop multiorgan failure, which is associated with high mortality. Bacterial infections are the most prevalent type of infection in patients with cirrhosis, with the prevalence of bacterial infections in patients admitted for an acute decompensating event ranging from 24% to 29%. Together with invasive fungal infections, bacterial infections are the most severe. Multidrug-resistant organisms have been evolving at a rapid and alarming rate around the world, which presents enormous challenges. The development of effective measures for the prevention, early detection, and treatment of infections in patients with cirrhosis is challenging, given the rising incidence of infections in this patient population.

Bridging the critically ill patient with acute to chronic liver failure to liver transplantation

Liver transplantation (LT) has emerged as an effective therapy for severe forms of acute-on-chronic liver failure (ACLF), an entity characterized by the development of multiorgan failure and high short-term mortality. The aim of critical care management of ACLF patients is to rapidly treat precipitating events and aggressively support failing organs to ensure that patients may successfully undergo LT or, less frequently, recover. Malnutrition and sarcopenia are frequently present, adversely impacting the prognosis of these patients. Management of critical care patients with ACLF is complex and requires the participation of different specialties. Once the patient is stabilized, a rapid evaluation for salvage LT should be performed because the time window for LT is often narrow. The development of sepsis and prolonged organ support may preclude LT or diminish its chances of success. The current review describes strategies to bridge severe ACLF patients to LT, highlights the minimal evaluation required for listing and the currently suggested contraindications to proceed with LT, and addresses different aspects of management during the perioperative and early posttransplant period.

Acute-on-chronic liver failure: a retrospective review of cases at a transplantation center in Brazil

PURPOSE

Acute-on-chronic liver failure (ACLF) is a leading cause of death in cirrhotic patients. This study aims to describe the outcomes of in-patients with ACLF at a liver transplantation (LT) center in Brazil.

METHODS

Retrospective study analyzing patient data from 2017 to 2022. Re-transplant cases and patients without previous chronic liver disease were excluded. The ACLF diagnosis was based on the European Association for the Study of the Liver-Chronic Liver Failure criteria and assessments repeated on days 3 and 7 after the initial diagnosis.

RESULTS

Among 381 patients, 10.49% (n = 40) were diagnosed with ACLF. Bacterial infection was the most common precipitating factor (45%). Kidney failure occurred in 65% of the cases. The 28-day mortality rate was 35% and varied according to ACLF severity at diagnosis, from single organ failure (ACLF-1) at 22% to three organ failures (ACLF-3) at 60%. Eighteen patients (45%) were transplanted with a 100% 28-day survival rate. For ACLF-3 cases at diagnosis (n = 15), the 28-day and 1-year survival rates with a transplant (n = 4) were 100% and 80%, respectively, and without transplant (n = 11), 10 and 0%, respectively.

CONCLUSIONS

ACLF was associated with high mortality rates. LT was an effective therapeutic option, particularly for ACLF-3 cases.

APASL clinical practice guidelines on the management of acute kidney injury in acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a syndrome that is characterized by the rapid development of organ failures predisposing these patients to a high risk of short-term early death. The main causes of organ failure in these patients are bacterial infections and systemic inflammation, both of which can be severe. For the majority of these patients, a prompt liver transplant is still the only effective course of treatment. Kidneys are one of the most frequent extrahepatic organs that are affected in patients with ACLF, since acute kidney injury (AKI) is reported in 22.8-34% of patients with ACLF. Approach and management of kidney injury could improve overall outcomes in these patients. Importantly, patients with ACLF more frequently have stage 3 AKI with a low rate of response to the current treatment modalities. The objective of the present position paper is to critically review and analyze the published data on AKI in ACLF, evolve a consensus, and provide recommendations for early diagnosis, pathophysiology, prevention, and management of AKI in patients with ACLF. In the absence of direct evidence, we propose expert opinions for guidance in managing AKI in this very challenging group of patients and focus on areas of future research. This consensus will be of major importance to all hepatologists, liver transplant surgeons, and intensivists across the globe.

Liver transplantation for acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) occurs in the context of advanced liver disease and is associated with hepatic and extrahepatic organ failure, eventually leading to a major risk of short-term mortality. To date, there are very few effective therapeutic options for ACLF. In many cases, liver transplantation is the only life-saving treatment that has acceptable outcomes in carefully selected recipients. This Review addresses key aspects of the use of liver transplantation for patients with ACLF, providing an in-depth discussion of existing evidence regarding candidate selection, the optimal window for transplantation, potential prioritisation of liver grafts for this indication, and the global management of ACLF to bridge patients to liver transplantation.

Outcome Predictors of Acute-on-Chronic Liver Failure: A Narrative Review

Complications of acute-on-chronic liver failure (ACLF) include increased short-term mortality. Extrahepatic organ failures result from chronic liver disease and acute hepatic injury. This combination characterizes end-stage liver disease. Its rapid progression makes it challenging for hepatologists and intensivists to treat. The varied definitions of this condition lead to varied clinical presentations. Hepatic or extrahepatic failures are more prevalent in chronic hepatitis B or cirrhosis patients who receive an additional injury. Numerous intensity parameters and prognosis ratings, including those for hepatitis B virus (HBV), have been developed and verified for various patients and causes of the disease. Liver regeneration, liver transplantation (LT), or antiviral therapy for HBV-related ACLF are the main treatment aims for various organ failures. LT is the best treatment for HBV-ACLF. In some HBV-related ACLF patients, nucleos(t)ide analogs and artificial liver assistance may enhance survival. Combining epidemiological and clinical studies, this review updates our understanding of HBV-ACLF's definition, diagnosis, epidemiology, etiology, therapy, and prognosis.

Use of the CytoSorb adsorber in patients with acute-on-chronic liver failure

CytoSorb is a hemoadsorptive column used to remove high concentrations of proinflammatory cytokines in septic shock. Data on CytoSorb application in acute-on-chronic liver failure (ACLF) is lacking. This retrospective observational study analyzed 21 ACLF patients admitted to ICUs at the Vienna General Hospital who received CytoSorb adsorber therapy between 2017 and 2023. Median ICU length of stay was 8 days (IQR: 3-13), the ICU survival rate was 23.8% (n = 5). Significant decreases in bilirubin (median peak: 20.7 mg/dL to median post-treatment: 10.8 mg/dL; - 47.8%; p < 0.001), procalcitonin (1.34 to 0.74 pg/mL; - 44.6%; p < 0.001), interleukin-6 (385 to 131 ng/mL; - 66.0%; p = 0.0182)-but also of platelets (72 to 31 G/L; - 56.9%; p = 0.0014) and fibrinogen (230 to 154 mg/dL; - 33.0%; p = 0.0297) were detected. ICU survivors had a trend towards a stronger relative decrease in bilirubin (- 76.1% vs. - 48.2%), procalcitonin (- 90.6% vs. - 23.5%), and IL-6 (- 54.6% vs. - 17.8%) upon CytoSorb treatment. Moreover, no serious CytoSorb-attributed complications were detected. In conclusion, use of CytoSorb adsorber in ACLF patients results in a significant decrease in bilirubin and proinflammatory cytokines, while platelets and fibrinogen were also lowered. Prospective trials are warranted to investigate the impact of CytoSorb on clinical outcomes of ACLF patients with high proinflammatory cytokine levels.

Older Patients With Acute on Chronic Liver Failure Have a Higher Waitlist Mortality, but Acceptable Post Liver Transplantation Survival When Compared to Younger Patients

BACKGROUND & AIMS

There is a paucity of studies on older patients (≥65 years) who develop acute on chronic liver failure (ACLF). The objectives of our study were to determine clinical characteristics and outcomes of older patients listed for liver transplantation (LT).

METHODS

Adults listed for LT with estimated ACLF (Est-ACLF) between 2005 and 2021 were identified using the United Network for Organ Sharing database and subdivided into older and younger age (18-64 years) groups. Kaplan-Meier survival analyses were used to evaluate survival, and a competing-risk model (Fine-Gray) was used to evaluate risk factors for survival on the waitlist. Logistic regression was done to evaluate risk factors.

RESULTS

A total of 4313 older (14%) and 26,628 younger (86%) patients were listed for LT, and 2142 (49.6%) and 16,931 (63.5%) were transplanted, respectively. Older patients had a higher 30-day waitlist mortality than younger patients (20.4% vs 16.7%; P < .0001); this was more pronounced in Est-ACLF-2 (23.7% vs 14.8%; P < .0001) and Est-ACLF-3 (43.3% vs 29.9%; P < .0001). One-year post-LT, patient survival in older patients with Est-ACLF grades 1, 2, and 3 were 86.4%, 85.5%, and 77% respectively; younger patients had better survival across all Est-ACLF grades. When adjusted for transplant eras, respiratory failure was the only independent risk factor for increased 1-year post-LT mortality in older patients.

CONCLUSION

Older patients with Est-CLF had significantly higher waitlist mortality than younger patients, but had acceptable 1-year post-LT survival including those with Est-ACLF-3; therefore, age alone should not be considered as a contraindication for LT. Older patients with respiratory failure should be carefully selected for LT.

Liver Transplantation in Chronic Liver Disease and Acute on Chronic Liver Failure- Indication, Timing and Practices

Liver transplantation (LT) is the second most common solid organ transplantation worldwide. LT is considered the best and most definitive therapeutic option for patients with decompensated chronic liver disease (CLD), hepatocellular carcinoma (HCC), acute liver failure (ALF), and acute-on-chronic liver failure (ACLF). The etiology of CLD shows wide geographical variation, with viral hepatitis being the major etiology in the east and alcohol-related liver disease (ALD) in the west. Non-alcoholic fatty liver disease (NAFLD) is on an increasing trend and is expected to be the most common etiology on a global scale. Since the first successful LT, there have been radical changes in the indications for LT. In many circumstances, not just the liver disease itself but factors such as extra-hepatic organ dysfunction or failures necessitate LT. ACLF is a dynamic syndrome that has extremely high short-term mortality. Currently, there is no single approved therapy for ACLF, and LT seems to be the only feasible therapeutic option for selected patients at high risk of mortality. Early identification of ACLF, stratification of patients according to disease severity, aggressive organ support, and etiology-specific treatment approaches have a significant impact on post-transplant outcomes. This review briefly describes the indications, timing, and referral practices for LT in patients with CLD and ACLF.

Comparison of fungal vs bacterial infections in the medical intensive liver unit: Cause or corollary for high mortality?

BACKGROUND

Due to development of an immune-dysregulated phenotype, advanced liver disease in all forms predisposes patients to sepsis acquisition, including by opportunistic pathogens such as fungi. Little data exists on fungal infection within a medical intensive liver unit (MILU), particularly in relation to acute on chronic liver failure.

AIM

To investigate the impact of fungal infections among critically ill patients with advanced liver disease, and compare outcomes to those of patients with bacterial infections.

METHODS

From our prospective registry of MILU patients from 2018-2022, we included 27 patients with culture-positive fungal infections and 183 with bacterial infections. We compared outcomes between patients admitted to the MILU with fungal infections to bacterial counterparts. Data was extracted through chart review.

RESULTS

All fungal infections were due to Candida species, and were most frequently blood isolates. Mortality among patients with fungal infections was significantly worse relative to the bacterial cohort (93% vs 52%, P < 0.001). The majority of the fungal cohort developed grade 2 or 3 acute on chronic liver failure (ACLF) (90% vs 64%, P = 0.02). Patients in the fungal cohort had increased use of vasopressors (96% vs 70%, P = 0.04), mechanical ventilation (96% vs 65%, P < 0.001), and dialysis due to acute kidney injury (78% vs 52%, P = 0.014). On MILU admission, the fungal cohort had significantly higher Acute Physiology and Chronic Health Evaluation (108 vs 91, P = 0.003), Acute Physiology Score (86 vs 65, P = 0.003), and Model for End-Stage Liver Disease-Sodium scores (86 vs 65, P = 0.041). There was no significant difference in the rate of central line use preceding culture (52% vs 40%, P = 0.2). Patients with fungal infection had higher rate of transplant hold placement, and lower rates of transplant; however, differences did not achieve statistical significance.

CONCLUSION

Mortality was worse among patients with fungal infections, likely attributable to severe ACLF development. Prospective studies examining empiric antifungals in severe ACLF and associations between fungal infections and transplant outcomes are critical.

Characteristics and risk factors for invasive fungal infection in hospitalized patients with acute-on-chronic hepatitis B liver failure: a retrospective cohort study from 2010 to 2023

BACKGROUND AND AIM

The global burden of invasive fungal infections (IFIs) is emerging in immunologic deficiency status from various disease. Patients with acute-on-chronic hepatitis B liver failure (ACHBLF) are prone to IFI and their conditions are commonly exacerbated by IFI. However, little is known about the characteristics and risk factors for IFI in hospitalized ACHBLF patients.

METHODS

A total of 243 hospitalized ACHBLF patients were retrospectively enrolled from January 2010 to July 2023. We performed restricted cubic spline analysis to determine the non-linear associations between independent variables and IFI. The risk factors for IFI were identified using logistic regression and the extreme gradient boosting (XGBoost) algorithm. The effect values of the risk factors were determined by the SHapley Additive exPlanations (SHAP) method.

RESULTS

There were 24 ACHBLF patients (9.84%) who developed IFI on average 17.5 (13.50, 23.00) days after admission. The serum creatinine level showed a non-linear association with the possibility of IFI. Multiple logistic regression revealed that length of hospitalization (OR = 1.05, 95% CI: 1.02-1.08, P = 0.002) and neutrophilic granulocyte percentage (OR = 1.04, 95% CI: 1.00-1.09, P = 0.042) were independent risk factors for IFI. The XGBoost algorithm showed that the use of antibiotics (SHAP value = 0.446), length of hospitalization (SHAP value = 0.406) and log (qHBV DNA) (SHAP value = 0.206) were the top three independent risk factors for IFI. Furthermore, interaction analysis revealed no multiplicative effects between the use of antibiotics and the use of glucocorticoids (P = 0.990).

CONCLUSION

IFI is a rare complication that leads to high mortality in hospitalized ACHBLF patients, and a high neutrophilic granulocyte percentage and length of hospitalization are independent risk factors for the occurrence of IFI.

Improving the radiological diagnosis of hepatic artery thrombosis after liver transplantation: Current approaches and future challenges

Hepatic artery thrombosis (HAT) is a devastating vascular complication following liver transplantation, requiring prompt diagnosis and rapid revascularization treatment to prevent graft loss. At present, imaging modalities such as ultrasound, computed tomography, and magnetic resonance play crucial roles in diagnosing HAT. Although imaging techniques have improved sensitivity and specificity for HAT diagnosis, they have limitations that hinder the timely diagnosis of this complication. In this sense, the emergence of artificial intelligence (AI) presents a transformative opportunity to address these diagnostic limitations. The develo pment of machine learning algorithms and deep neural networks has demon strated the potential to enhance the precision diagnosis of liver transplant com plications, enabling quicker and more accurate detection of HAT. This article examines the current landscape of imaging diagnostic techniques for HAT and explores the emerging role of AI in addressing future challenges in the diagnosis of HAT after liver transplant.

Acute decompensation of cirrhosis versus acute-on-chronic liver failure: What are the clinical implications?

It is essential to identify the subgroup of patients who experience poorer outcomes in order to adapt clinical management effectively. In the context of liver disease, the earlier the identification occurs, the greater the range of therapeutic options that can be offered to patients. In the past, patients with acute decompensation (AD) of chronic liver disease were treated as a homogeneous group, with emphasis on identifying those at the highest risk of death. In the last 15 years, a differentiation has emerged between acute-on-chronic liver failure syndrome (ACLF) and AD, primarily due to indications that the latter is linked to a less favorable short-term prognosis. Nevertheless, the definition of ACLF varies among the different knowledge societies, making it challenging to assess its true impact compared with AD. Therefore, the purpose of this review is to provide a detailed analysis emphasizing the critical importance of identifying ACLF in the field of advanced liver disease. We will discuss the differences between Eastern and Western approaches, particularly in relation to the occurrence of liver failure and disease onset. Common characteristics, such as the dynamic nature of the disease course, will be highlighted. Finally, we will focus on two key clinical implications arising from these considerations: the prevention of ACLF before its onset and the clinical management strategies once it develops, including liver transplantation and withdrawal of care.

Evolution of Liver Transplantation Indications: Expanding Horizons

Liver transplantation (LT) has significantly transformed the prognosis of patients with end-stage liver disease and hepatocellular carcinoma (HCC). The traditional epidemiology of liver diseases has undergone a remarkable shift in indications for LT, marked by a decline in viral hepatitis and an increase in metabolic dysfunction-associated steatotic liver disease (MASLD), along with expanded indications for HCC. Recent advancements in surgical techniques, organ preservation and post-transplant patients' management have opened new possibilities for LT. Conditions that were historically considered absolute contraindications have emerged as potential new indications, demonstrating promising results in terms of patient survival. While these expanding indications provide newfound hope, the ethical dilemma of organ scarcity persists. Addressing this requires careful consideration and international collaboration to ensure equitable access to LT. Multidisciplinary approaches and ongoing research efforts are crucial to navigate the evolving landscape of LT. This review aims to offer a current overview of the primary emerging indications for LT, focusing on acute-on-chronic liver failure (ACLF), acute alcoholic hepatitis (AH), intrahepatic and perihilar cholangiocarcinoma (i- and p-CCA), colorectal liver metastasis (CRLM), and neuroendocrine tumor (NET) liver metastases.

Acute on Chronic Liver Failure: Lessons from a Decade of EASL-CLIF Definition and Scoring Systems

How to cite this article: Solao V. Acute on Chronic Liver Failure: Lessons from a Decade of EASL-CLIF Definition and Scoring Systems. Indian J Crit Care Med 2024;28(2):100-102.