Only in the darkness can you see the stars: Severe alcoholic hepatitis and higher grades of acute-on-chronic liver failure

Philips, Cyriac Abby; Augustine, Philip; Padsalgi, Guruprasad; Ahamed, Rizwan; Jose, Amal; Rajesh, S

doi:10.1016/j.jhep.2018.10.004

Cited by 16 publications

(14 citation statements)

References 7 publications

(3 reference statements)

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“…The best proof that sepsis can be improved with modulation of gut microbiota stems from studies of healthy donor faecal microbiota transplantation (currently rechristened intestinal microbiota reinstitution therapy or intestinal microbiota re-instituition therapy) in patients with recurrent and severe Clostridium difficile infections[ 80 - 82 ]. Modulation of microbiota in a similar fashion in patients with liver disease has been shown to improve outcomes related to hepatic encephalopathy, alcoholic hepatitis with infections, ACLF, and primary sclerosing cholangitis with recurrent cholangitis[ 83 - 86 ]. In patients with cirrhosis, understanding the gut microbiota and its modulation are still in foetal stages.…”

Section: The Role Of and Modulation Of Gut Microbiota In Sepsis And Cmentioning

confidence: 99%

Update on diagnosis and management of sepsis in cirrhosis: Current advances

Philips¹,

Ahamed²,

Rajesh³

et al. 2020

WJH

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Sepsis and septic shock are catastrophic disease entities that portend high mortality in patients with cirrhosis. In cirrhosis, hemodynamic perturbations, immune dysregulation, and persistent systemic inflammation with altered gut microbiota in the background of portal hypertension enhance the risk of infections and resistance to antimicrobials. Patients with cirrhosis develop recurrent life-threatening infections that progress to multiple organ failure. The definition, pathophysiology, and treatment options for sepsis have been ever evolving. In this exhaustive review, we discuss novel advances in the understanding of sepsis, describe current and future biomarkers and scoring systems for sepsis, and delineate newer modalities and adjuvant therapies for the treatment of sepsis from existing literature to extrapolate the same concerning the management of sepsis in cirrhosis. We also provide insights into the role of gut microbiota in initiation and progression of sepsis and finally, propose a treatment algorithm for management of sepsis in patients with cirrhosis.

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Section: The Role Of and Modulation Of Gut Microbiota In Sepsis And Cmentioning

confidence: 99%

Update on diagnosis and management of sepsis in cirrhosis: Current advances

Philips¹,

Ahamed²,

Rajesh³

et al. 2020

WJH

Self Cite

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“…A retrospective study on 23 patients with alcoholic hepatitis and ACLF, ineligible for either corticosteroid treatment or liver transplantation, received faecal microbiota transplantation. This study showed survival rates of 73% for patients with ACLF-1 and 58% for ACLF-2 or ACLF-3 after 548 days 67. Again, these results are insufficient to make specific recommendations regarding this intervention for treating ACLF, however, they are encouraging and point to more pathophysiologically relevant therapeutic targets.…”

Section: Managementmentioning

confidence: 75%

“…Faecal microbiota transplantation has also been explored in a few pilot studies and has been shown to have beneficial effects on the outcomes of patients with alcohol-related ACLF 66 67. A retrospective study on 23 patients with alcoholic hepatitis and ACLF, ineligible for either corticosteroid treatment or liver transplantation, received faecal microbiota transplantation.…”

Section: Managementmentioning

confidence: 99%

Acute-on-chronic liver failure: definition, prognosis and management

Amin

Mookerjee

2019

Frontline Gastroenterol

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Acute-on-chronic liver failure (ACLF) is a recently described entity in chronic liver disease defined by acute hepatic decompensation, organ failure and a high risk of short-term mortality (usually less than 4 weeks). This condition is distinct from acute liver failure and stable progression of cirrhosis in numerous ways, including triggering precipitant factors, systemic inflammation, rapid progression and a potential for recovery. While a clear definition of ACLF has been forwarded from a large European Consortium study, some heterogeneity remains in how patients present and the types of organ failure, depending on whether they are described in Asian or European studies. Active alcoholism, acute alcoholic hepatitis and infections are the most frequent precipitants for ACLF. Underpinning the pathophysiology of ACLF is a state of persistent inflammation and immune dysfunction, collectively driving a systematic inflammatory response syndrome and an increased propensity to sepsis. Prevention and early treatment of organ failure are key in influencing survival. Given increasing organ shortage and more marginal grafts, liver transplantation is a limited resource and emphasises the need for new therapies to improve ACLF outcomes. Recent data indicate that liver transplantation has encouraging outcomes even in patients with advanced ACLF if patients are carefully selected during the permissive window of clinical presentation. ACLF remains a significant challenge in the field of hepatology, with considerable research and resource being channelled to improve upon the definition, prognostication, treatment and unravelling of mechanistic drivers. This Review discusses updates in ACLF definition, prognosis and management.

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“…Some pilot studies suggest that healthy donor faecal microbiota transplantation has a beneficial effect on the outcome of patients with alcoholrelated ACLF. 58,59 A retrospective uncontrolled study on 23 patients with sAH and ACLF not eligible for corticosteroids and not undergoing liver transplantation (LT) but receiving salvage faecal microbiota transplantation showed promising survival rates of 73% for patients with ACLF-1 and 58% for ACLF-2 or 3 at 548 days. 59 Unfortunately, it is not currently possible to make a clear recommendation about this emerging therapy, as highquality trials are lacking.…”

Section: Prognosis Of Aclf In Patients With Aldmentioning

confidence: 99%

Acute-on-chronic liver failure in patients with alcohol-related liver disease

Gustot

Jalan

2019

Journal of Hepatology

113

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The spectrum of alcohol-related liver diseases (ALD) includes steatosis, steatohepatitis, progressive liver fibrosis, and cirrhosis. Acute-on-chronic liver failure (ACLF) is a recently defined entity that occurs in patients with chronic liver diseases and is characterised by acute decompensation, organ failures and a high risk of short-term mortality. Active alcohol consumption, alcoholic hepatitis and bacterial infections are the most frequent events precipitating the development of ACLF in the context of ALD (ALD-ACLF). The specific management of this entity remains unknown and the place of salvage liver transplantation controversial. This overview details the current knowledge on specific aspects of epidemiology, pathophysiology, prognosis and management of ALD-ACLF.

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Only in the darkness can you see the stars: Severe alcoholic hepatitis and higher grades of acute-on-chronic liver failure

Cited by 16 publications

References 7 publications

Update on diagnosis and management of sepsis in cirrhosis: Current advances

Update on diagnosis and management of sepsis in cirrhosis: Current advances

Acute-on-chronic liver failure: definition, prognosis and management

Acute-on-chronic liver failure in patients with alcohol-related liver disease

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