New concepts in acute‐on‐chronic liver failure: Implications for liver transplantation

Abstract

Acute‐on‐chronic liver failure (ACLF) is a recently defined syndrome that occurs frequently in patients with cirrhosis and is associated with a poor short‐term prognosis. Currently, management of patients with ACLF is mainly supportive. Despite medical progress, this syndrome frequently leads to multiorgan failure, sepsis, and, ultimately, death. The results of attempts to use liver transplantation (LT) to manage this critical condition have been poorly reported but are promising. Currently, selection criteria of ACLF patients for LT, instructions for prioritization on the waiting list, and objective indicators for removal of ACLF patients from the waiting list in cases of clinical deterioration are poorly defined. Before potential changes can be implemented into decisional algorithms, their effects, either on the benefits to individual patients or on global transplant outcomes, should be carefully evaluated using objective longterm endpoints that take into account ethical considerations concerning LT. Liver Transplantation 23 234–243 2017 AASLD

Differential characteristics and prognosis of patients with hepatitis B virus‐related acute‐on‐chronic liver failure defined by European Association for the Study of the Liver – Chronic Liver Failure criteria

“…This information is of clinical significance in determining the treatment of HBV‐related ACLF patients. Liver transplantation should be given a high priority in HBV‐related APASL ACLF patients who meet the EASL‐CLIF ACLF criteria due to their extremely high mortality . For patients without EASL‐CLIF ACLF, attention should be focused on intensive monitoring and early treatment of bacterial infection, AKI, and extrahepatic organ failure.…”

“…Liver transplantation should be given a high priority in HBV-related APASL ACLF patients who meet the EASL-CLIF ACLF criteria due to their extremely high mortality. 23 For patients without EASL-CLIF ACLF, attention should be focused on intensive monitoring and early treatment of bacterial infection, AKI, and extrahepatic organ failure. Table 4 Comparison of prognostic scores in predicting short-term mortality in the entire cohort of patients with hepatitis B virus-related acute-on-chronic liver failure (ACLF) according to the European Association for the Study of the Liver -Chronic Liver Failure (CLIF) classification 28-day transplant-free mortality 90-day transplant-free mortality AUROC (95% CI) P-value vs. CLIF-C ACLFs AUROC (95% CI) P-value vs. CLIF-C ACLFs ADs, acute decompensation score; AUROC, area under the receiver operating characteristic curve; CLIF-C, Chronic Liver Failure Consortium; CPs, Child-Pugh score; OFs, organ failure score; MELDs, Model for End-stage Liver Disease score; MELD-Nas, MELDsodium score.…”

Liver transplantation in acute-on-chronic liver failure

“…[ 15] In summary, 3 points relating to transplantation in ACLF: firstly, improvement or worsening in ACLF grade occur rapidly and likely survival is best predicted at 3-7 days; secondly, transplantation gives good results in those with deteriorating ACLF grades 2 to 3 but timing, priority and selection criteria need to be defined; thirdly, liver support devices, plasma exchange, anti-inflammatory agents and stimulation of regeneration require further evaluation.…”

Liver transplantation in the most severely ill cirrhotic patients

“…We also support very short selection processes in order to reduce the risks of complications and the deterioration of multiorgan failures causing potential preventable death and reducing the probabilities of a patient being transplanted just in time [3].…”