Hepatic and systemic hemodynamic derangements predict early mortality and recovery in patients with acute‐on‐chronic liver failure

Garg, Hitendra; Kumar, Ashish; Garg, Vishal; Kumar, Manoj; Kumar, Ramesh; Sharma, Barjesh Chander; Sarin, Shiv Kumar

doi:10.1111/jgh.12191

Cited by 52 publications

(28 citation statements)

References 21 publications

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“…The mean HVPG in our cirrhotic cohort was 15.8 ± 6.2 mmHg. This is similar to the studies published by Kim et al (10) and Garg et al, (11) which reported a mean HVPG of 15.6 ± 5.1 mmHg and median HVPG of 16 (range 12-30) mmHg, respectively. Despite a small sample size, our study demonstrated a significant difference (p = 0.04) in the risk of variceal bleeding in cirrhotics with a HVPG ≥ 12 mmHg compared with those with a HVPG < 12 mmHg.…”

Section: Discussionsupporting

confidence: 81%

Application of a standardised protocol for hepatic venous pressure gradient measurement improves quality of readings and facilitates reduction of variceal bleeding in cirrhotics

Tey

Gogna

Irani

et al. 2016

smedj

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INTRODUCTIONHepatic venous pressure gradient (HVPG) measurement is recommended for prognostic and therapeutic indications in centres with adequate resources and expertise. Our study aimed to evaluate the quality of HVPG measurements at our centre before and after introduction of a standardised protocol, and the clinical relevance of the HVPG to variceal bleeding in cirrhotics.METHODS HVPG measurements performed at Singapore General Hospital from 2005-2013 were retrospectively reviewed.Criteria for quality HVPG readings were triplicate readings, absence of negative pressure values and variability of ≤ 2 mmHg. The rate of variceal bleeding was compared in cirrhotics who achieved a HVPG response to pharmacotherapy (reduction of the HVPG to < 12 mmHg or by ≥ 20% of baseline) and those who did not.RESULTS 126 HVPG measurements were performed in 105 patients (mean age 54.7 ± 11.4 years; 55.2% men). 80% had liver cirrhosis and 20% had non-cirrhotic portal hypertension (NCPH). The mean overall HVPG was 13.5 ± 7.2 mmHg, with a significant difference between the cirrhosis and NCPH groups (p < 0.001). The proportion of quality readings significantly improved after the protocol was introduced. HVPG response was achieved in 28 (33.3%, n = 84) cirrhotics. Nine had variceal bleeding over a median follow-up of 29 months. The rate of variceal bleeding was significantly lower in HVPG responders compared to nonresponders (p = 0.025). CONCLUSIONThe quality of HVPG measurements in our centre improved after the introduction of a standardised protocol. A HVPG response can prognosticate the risk of variceal bleeding in cirrhotics.

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Section: Discussionsupporting

confidence: 81%

Application of a standardised protocol for hepatic venous pressure gradient measurement improves quality of readings and facilitates reduction of variceal bleeding in cirrhotics

Tey

Gogna

Irani

et al. 2016

smedj

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“…The fact that the prevalence of extrahepatic organ failure is not higher in the extrahepatic insult group emphasizes that the final common pathway of deterioration and mortality in ACLF is systemic inflammation and subsequent circulatory dysfunction resulting in multiorgan failure 19,20 irrespective of the cause of acute insult. In our previous study, we reported increasing inhospital mortality with increasing numbers of organ failures (26% with single organ failure and 58%, 71%, and 100% with two, three, and four organ failures, respectively) in ACLF.…”

Section: Discussionmentioning

confidence: 95%

Impact of Hepatic and Extrahepatic Insults on the Outcome of Acute-on-Chronic Liver Failure

Gupta

Dhiman

Rathi

et al. 2017

Journal of Clinical and Experimental Hepatology

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Background: To study the differences in outcome and predictors of mortality in acute-on-chronic liver failure (ACLF) precipitated by hepatic or extrahepatic insults. Methods: Consecutive patients of cirrhosis with acute decompensation were prospectively included and followed up for 90 days from admission. ACLF was defined based on chronic liver failure (CLIF) acute-on-chronic liver failure in cirrhosis (CANONIC study) criteria. Acute worsening due to acute viral hepatitis A and E, hepatitis B flare, alcoholic hepatitis, autoimmune hepatitis flare, or drug-induced liver injury were categorized as hepatic ACLF and that due to bacterial infection, upper gastrointestinal bleed or surgery as extrahepatic ACLF. Patients with both hepatic and extrahepatic insults were included in combined insult group. Results: Of 179 patients of acute decompensation, 122 had ACLF (hepatic insults 47 and extrahepatic insults 51). Alcohol (64.8%) was the most common etiology of cirrhosis while infection (36%) was the most common acute insult followed by alcoholic hepatitis (24.6%). Higher proportion of extrahepatic ACLF patients had history of prior decompensation than hepatic ACLF patients (62.7% vs. 27.7%, P < 0.001). There was no difference in mortality among hepatic and extrahepatic ACLF groups at 28 and 90 days (53.2% vs. 56.9%, P = 0.715 and 85% vs. 74.5%, P = 0.193, respectively). Area under receiver-operating curve (AUROC) for 28-day mortality in extrahepatic ACLF group was 0.788, 0.724, 0.718, 0.634, and 0.726 and in hepatic-ACLF group was 0.786, 0.625, 0.802, 0.761, and 0.648 for chronic liver failure-sequential organ failure assessment (CLIF-SOFA), model for end stage liver disease (MELD), integrated MELD score (iMELD), acute physiology and chronic health evaluation score (APACHE-II), and Child-Turcotte-Pugh score scores, respectively. Conclusion: There is no difference in mortality among hepatic and extrahepatic ACLF groups at 28 and 90 days. iMELD and CLIF-SOFA have highest AUROC to predict 28-day mortality in hepatic and extrahepatic ACLF groups, respectively. ( J CLIN EXP HEPATOL 2017;7:9-15)

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“…6 Furthermore, the CANONIC study was conducted in a European population, and there have been only a few published studies on the outcome of ACLF in an Asian population to date. 13,14 In the present study, hospitalized patients with active alcoholism and severe form of alcoholic liver disease who developed ACLF more frequently had an infection and SIRS and higher MELD, MELD-Na, and severity scores for alcoholic liver disease such as MDF and ABIC.…”

Section: Discussionmentioning

confidence: 96%

Characterization of acute‐on‐chronic liver failure and prediction of mortality in Asian patients with active alcoholism

Kim

Chang

Park

et al. 2016

J of Gastro and Hepatol

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Hepatic and systemic hemodynamic derangements predict early mortality and recovery in patients with acute‐on‐chronic liver failure

Cited by 52 publications

References 21 publications

Application of a standardised protocol for hepatic venous pressure gradient measurement improves quality of readings and facilitates reduction of variceal bleeding in cirrhotics

Application of a standardised protocol for hepatic venous pressure gradient measurement improves quality of readings and facilitates reduction of variceal bleeding in cirrhotics

Impact of Hepatic and Extrahepatic Insults on the Outcome of Acute-on-Chronic Liver Failure

Characterization of acute‐on‐chronic liver failure and prediction of mortality in Asian patients with active alcoholism

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