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

Abstract

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)

Flare of Autoimmune Hepatitis Causing Acute on Chronic Liver Failure: Diagnosis and Response to Corticosteroid Therapy

“…The study showed the prevalence of AIH flare as a cause of ACLF in 2.8% of the ACLF patient cohort. This is in concordance with another study (20) in which AIH flare accounted for 2.5% of ACLF patients. DILI and acute viral hepatitis were found to precipitate flare of AIH in approximately 17% of patients.…”

Paradigm shift in Etiology of Upper Gastrointestinal Bleed in Emergency Department

“…Singh et al recently reported that alcohol-related disease, not HBV, is the major cause of liver cirrhosis in Asia (11). We had also reported alcohol in 58-66% of patients, followed by NASH in 9-14% of patients, as a cause of cirrhosis (12)(13)(14). This is in accordance with Western data where NASH-related CLD is an upcoming epidemic and is becoming the leading cause of liver transplantation (15).…”

Current Diagnosis and Classification of Hepatic Encephalopathy

“…20 The main reason behind this proposal is the more severe prognostic value of HE in the context of ACLF, 21 even if there is no proof of peculiar pathophysiological mechanisms. 22 The finding that the increased brain water content is parallel with the degree of HE 23 is in line with the view of increased astrocyte hydration in HE. 24 It should be emphasized that the concept of brain hyperhydration ('edema') should not be confused with the one of intracranial hypertension.…”