Increased Survival for Patients With Cirrhosis and Organ Failure in Liver Intensive Care and Validation of the Chronic Liver Failure–Sequential Organ Failure Scoring System

McPhail, Mark; Shawcross, Debbie L.; Abeles, R.D.; Chang, Anthony; Patel, Vishal C.; Lee, Guan Huei; Abdulla, Maheeba; Sizer, Elizabeth; Willars, Christopher; Auzinger, G.; Bernal, William; Wendon, Julia

doi:10.1016/j.cgh.2014.08.041

Cited by 92 publications

(99 citation statements)

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“…Refusal of cirrhotic patients with organ failure to the ICU may no longer be justifiable considering that the mortality of these patients when admitted to an ICU seems to be decreasing over the last decade (8). In fact, half of ACLF patients improve or the syndrome is resolved when best supportive care is given, and shortterm mortality of ACLF patients enrolled in the CANON-IC study was similar to that described for septic shock in the general population (8,9,22). However, ICU admission may not be feasible due to the high prevalence of the syndrome in a limited ICU bed availability setting.…”

Section: Discussionmentioning

confidence: 99%

“…However, the acceptance of cirrhotic patients in ICU has been hampered by their high mortality, high costs per admission, and scarcity of ICU beds (5-7). As improved management of these patients led to improved outcomes in the intensive care setting, the refusal of admission of ACLF patients to an ICU may no longer be justifiable (6,8). Evidence on whom and when to transfer to an ICU is sparse, but recently it has been argued that ACLF should be managed in these units (9).…”

Section: Introductionmentioning

confidence: 99%

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CLIF-C ACLF score is a better mortality predictor than MELD, MELD-Na and CTP in patients with Acute on Chronic Liver Failure admitted to the ward

et al. 2017

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Background and aims: Acute-on-chronic liver failure (ACLF) is a frequent syndrome associated with high mortality. The aims of the present study are: a) comparing the Chronic Liver Failure Consortium (CLIF-C) ACLF Model for End-Stage Liver Disease (MELD), MELD Sodium (MELD-Na) and Child-TurcottePugh (CTP) scores for prediction of short/medium term mortality; b) identifying ACLF prevalence in patients admitted to the ward; and c) comparing mortality between non-ACLF/ACLF.Methods: Retrospective cohort study of 177 patients admitted to the Gastroenterology ward for acute decompensation of cirrhosis.Results: We included 132 males. Alcohol was the cirrhosis cause/co-factor in 79.7% of cases. Infection was present in 40.7%. At admission, 19.8% of patients presented ACLF and 7.9% developed it during hospitalization (overall prevalence was 27.7%). ACLF grade 1 was diagnosed in 55.1% of the ACLF patients; grade 2, in 42.8%, and grade 3, in 2.0%. Infection (p < 0.001) and hepatic encephalopathy (p = 0.004) were more prevalent and C-reactive protein and leukocyte counts were higher in ACLF patients. ACLF 28 and 90-day mortality was 45.8% and 60.4%, respectively. The CLIF-C ACLF score was significantly superior to CTP, MELD, MELD-Na in predicting 28-day (AUROC 0.799 ± 0.078, 95% CI 0.637-0.891) and 90-day mortality (AUROC 0.828 ± 0.063, 95% CI 0.705-0.952).Conclusion: ACLF is highly prevalent in the ward. The new CLIF scores identify high mortality cirrhotic patients admitted to the ward and are better than their predecessors to predict ACLF patients' short/medium term mortality.

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Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

CLIF-C ACLF score is a better mortality predictor than MELD, MELD-Na and CTP in patients with Acute on Chronic Liver Failure admitted to the ward

et al. 2017

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“…The MELD and Child-Pugh systems were found to underestimate the risk of mortality in ACLF, while the CLIF-C ACLF score, which measures both hepatic and extrahepatic organ dysfunction, was found to discriminate between survivors and non-survivors significantly more accurately. It could, therefore, be suggested that, while MELD and Child-Pugh scores may be useful to assess patients' eligibility for transplantation, they do not have the accuracy, precision or prognostic value to act as the only systems to evaluate the fruitlessness of continued care [29] . While there are clear determinants of poor prognosis in cirrhotic patients, including the severity of liver dysfunction and presence of organ failure, mortality rates continue to vary widely; this is probably due to the heterogeneous nature of liver ICU admission criteria across different hospitals.…”

Section: Clinical and Prognostic Factorsmentioning

confidence: 99%

Acute-on-chronic liver failure: recent update

Alam

Suen

2016

J Biomed Res

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Acute on chronic liver failure (ACLF) was first described in 1995 as a clinical syndrome distinct to classic acute decompensation. Characterized by complications of decompensation, ACLF occurs on a background of chronic liver dysfunction and is associated with high rates of organ failure and significant short-term mortality estimated between 45% and 90%. Despite the clinical relevance of the condition, it still remains largely undefined with continued disagreement regarding its precise etiological factors, clinical course, prognostic criteria and management pathways. It is concerning that, despite our relative lack of understanding of the condition, the burden of ACLF among cirrhotic patients remains significant with an estimated prevalence of 30.9%. This paper highlights our current understanding of ACLF, including its etiology, diagnostic and prognostic criteria and pathophysiology. It is evident that further refinement of the ACLF classification system is required in order to detect high-risk patients and improve short-term mortality rates. The field of metabolomics certainly warrants investigation to enhance diagnostic and prognostic parameters, while the use of granulocyte-colony stimulating factor is a promising future therapeutic intervention for patients with ACLF.

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“…Outcomes from the intensive care unit are reasonably good (overall >50% survival to hospital discharge), particularly for acutely reversible complications, such as a GI bleed or encephalopathy. 30 It is important to regularly review progress of patients to avoid prolonged futile admissions. Escalation or palliative care plans should be clearly documented by the specialist teams to avoid difficult decisions for on-call teams.…”

Section: Nutritionmentioning

confidence: 99%

Management of decompensated cirrhosis

Mansour

McPherson

2018

Clinical Medicine

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: s60-s5 of hepatic decompensation through a careful history, examination and investigations so appropriate treatment can be given. Assessment of a patient with decompensated cirrhosisInitial assessment of a patient with decompensated cirrhosis in the acute setting can be performed using the ABC (airway, breathing, circulation) approach. AirwayThe airway can be compromised in patients with severe hepatic encephalopathy where their conscious level is reduced (grade 3 or 4) or in those who present with large volume haematemesis. In these circumstances, early intubation and ventilation must be considered. BreathingBreathing is commonly compromised in patients with cirrhosis. Common causes of impaired breathing in cirrhotic patients include pneumonia (including aspiration pneumonia), pulmonary oedema (due to alcohol-related, ischaemic or cirrhotic cardiomyopathy), hepatic hydrothorax and gross ascites causing splinting of the diaphragm. Breathlessness can also be due to pulmonary complications of portal hypertension, namely portopulmonary hypertension (defined as pulmonary artery pressure >25 mmHg in a patient with portal hypertension and no other cause) and hepatopulmonary syndrome (HPS; triad of liver dysfunction, intrapulmonary vasodilation and arterial oxygenation defect). HPS is characterised by platypnoea and orthodeoxia (dyspnoea and hypoxia worse in the upright position and improved by lying flat) and can be diagnosed on bubble echocardiography. Both portopulmonary hypertension and HPS improve following liver transplant.Breathing should be assessed by respiratory rate, oxygen saturations and auscultation of the chest. In the context of tense ascites, early paracentesis can improve respiratory function. CirculationHypotension and tachycardia can occur as a result of sepsis, hypovolaemia/overdiuresis and GI bleeding. Tachycardia may not be present in subjects with significant hypovolaemia who are on beta-blockers. While it is important to identify and ameliorate the cause, the initial focus should be on adequate resuscitation. Hypovolaemic or shocked patients should be fluid resuscitated in IntroductionDecompensated cirrhosis is a frequent reason for admission to the acute medical unit, and such patients typically have complex medical needs that can lead to a prolonged hospital stay and a significant risk of an in-hospital death (10-20%). It is therefore vital that these patients receive the appropriate investigations and treatment as early as possible in their patient journey. The aim of this review is to provide an overview of the management of decompensated cirrhosis for non-specialists.Decompensated cirrhosis is defined as an acute deterioration in liver function in a patient with cirrhosis and is characterised by jaundice, ascites, hepatic encephalopathy, hepatorenal syndrome or variceal haemorrhage. Common precipitants of hepatic decompensation include infections, gastrointestinal (GI) bleeding, high alcohol intake / alcohol-related hepatitis or drug-induced liver injury although no specific cause is fo...

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Increased Survival for Patients With Cirrhosis and Organ Failure in Liver Intensive Care and Validation of the Chronic Liver Failure–Sequential Organ Failure Scoring System

Cited by 92 publications

References 20 publications

CLIF-C ACLF score is a better mortality predictor than MELD, MELD-Na and CTP in patients with Acute on Chronic Liver Failure admitted to the ward

CLIF-C ACLF score is a better mortality predictor than MELD, MELD-Na and CTP in patients with Acute on Chronic Liver Failure admitted to the ward

Acute-on-chronic liver failure: recent update

Management of decompensated cirrhosis

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