Non-hepatic Insults Are Common Acute Precipitants in Patients with Acute on Chronic Liver Failure (ACLF)

Duseja, Ajay; Chawla, Yogesh; Dhiman, Radha K.; Kumar, Amit; Choudhary, Narendra S.; Taneja, Sunil

doi:10.1007/s10620-010-1377-0

Cited by 73 publications

(84 citation statements)

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“…The best prognostic score for hepatic group is iMELD and for extrahepatic group is CLIF-SOFA. Similar to our previous data, 7,8 in the present study, alcohol was the predominant cause of chronic liver disease, alcoholic hepatitis was the most common hepatic insult, and infection was the most common extrahepatic insult. This is in contrast to studies from East Asia where hepatitis B is the predominant cause of chronic liver disease as well as acute insult in patients with ACLF.…”

Section: Discussionsupporting

confidence: 92%

“…The APASL group considers only hepatic insults/injury as acute precipitating event, whereas EASL also includes extrahepatic insult such as the sepsis and upper gastrointestinal bleeding as a cause of acute insult. 2,[4][5][6][7] The chronic liver failure (CLIF) acute-on-chronic liver failure in cirrhosis (CANONIC) study has defined ACLF based on increased 28-day mortality in patients with liver cirrhosis and acute decompensation. In a previous study, we have demonstrated chronic liver failure-sequential organ failure assessment (CLIF-SOFA) criteria to be better than APASL criteria in defining ACLF.…”

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confidence: 99%

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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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Section: Discussionsupporting

confidence: 92%

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confidence: 99%

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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“…A minor acute insult may be enough to cause the ACLF in a patient with severe underlying chronic liver disease, and a severe acute insult may be required in a patient who has mild underlying chronic liver disease. 7,14 Both hepatic and non-hepatic insults could occur as acute precipitating events leading to the syndrome of ACLF. The 'hepatic' precipitating events, that directly exaggerate the liver injury, are alcoholic hepatitis, drug-induced liver injury, superimposed viral hepatitis, portal vein thrombosis and ischemic hepatitis.…”

Section: Concept Of Acute-on-chronic Liver Failurementioning

confidence: 99%

“…17 Subsequently, many publications have reported HEV as one of the leading causes for decompensation of cirrhosis from Asia and Africa, where HEV is endemic (Table 1). 14,15,[17][18][19][20][21][22][23][24][25][26][27][28][29][30][31][32][33] Most of these studies have used the APASL definition of ACLF and in median21% of cases (range 4-72%) of ACLF, HEV was the precipitating cause for liver decompensation. This contrasts with the Western countries where HEV is rarely the precipitating cause of acute decompensation in ACLF.…”

Section: Role Of Hepatitis E Virus In Acute-on-chronic Liver Failurementioning

confidence: 99%

Hepatitis E and Acute-on-Chronic Liver Failure

Kumar

Saraswat

2013

Journal of Clinical and Experimental Hepatology

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Hepatitis E virus (HEV) is the most common cause of acute viral hepatitis (AVH) globally. It causes large scale epidemics of AVH across the low-and middle income countries in Asia and Africa, and also causes sporadic cases of AVH in the same geographical region. AVH due to HEV is usually an acute, self-limiting illness, similar in clinical presentation to AVH caused by hepatitis A virus (HAV). When HEV causes AVH in patients of chronic liver disease it may worsen rapidly to a syndrome called acute-on-chronic liver failure (ACLF) leading to very high mortality. Acute deterioration of liver function in a patient with compensated chronic liver disease is the characteristic feature of ACLF. The typical disease course of patients with ACLF is the appearance of organ failure, which progresses to multi-organ failure and death. Many publications have reported HEV as one of the leading causes for ACLF from Asia and Africa, where HEV is endemic. The mortality rate of HEV-related ACLF (HEV-ACLF) ranges from 0% to 67% with a median being 34%. These patients require admission in the intensive care unit and they benefit from a team approach of clinicians with expertise in both hepatology and critical care. The goals of treatment are to prevent further deterioration in liver function, reverse precipitating factors, and support failing organs. Liver transplantation is required in selected patients to improve survival and quality of life. One preliminary report suggests that ribavirin may be an effective and safe drug for treatment of HEV-ACLF however this requires validation in large trials. ( J CLIN EXP HEPATOL 2013;3:225-230)

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“…6,7 ATT constitutes an important acute precipitating event in decompensation of underlying known or unknown liver disease in India. 8 There is paucity of data in defining hepatotoxicity in patients with cirrhosis and clear guidelines do not exist regarding the monitoring of such patients, modification of the antitubercular regimen and mode of reintroduction of individual antitubercular therapy. Little is known about the characteristics of TB in patients with liver cirrhosis.…”

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Clinical and Biochemical Profile of Tuberculosis in Patients with Liver Cirrhosis

Sharma

Tyagi

Singla

et al. 2015

Journal of Clinical and Experimental Hepatology

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Non-hepatic Insults Are Common Acute Precipitants in Patients with Acute on Chronic Liver Failure (ACLF)

Abstract: ACLF is a common problem in our clinical practice. Non-hepatic insults like non-hepatotropic infections/sepsis are common acute precipitating events.

Cited by 73 publications

References 20 publications

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

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

Hepatitis E and Acute-on-Chronic Liver Failure

Clinical and Biochemical Profile of Tuberculosis in Patients with Liver Cirrhosis

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