Acute on chronic liver failure- etiology, clinical profile, prognostic scores: experience from tertiary care centre of eastern India
Keywords:Acute on chronic liver disease, Chronic liver disease, CLIF-ACLF, Cuttack
Background: Acute on chronic liver failure (ACLF) is a recently recognised entity in chronic liver disease patients. Data regarding ACLF in terms of clinical presentation, etiology of underlying cirrhosis, precipitating factors, prognostic factors are lacking from eastern India. The present study was undertaken to evaluate the above factors along with the assessment of short-term mortality (4 weeks) in patients of ACLF.
Methods: In this prospective observational study, 120 patients diagnosed as ACLF were included. A comparison of complications, biochemical profiles and prognostic scores was made between the survivor and non-survivor groups.
Results: Of the 120 ACLF patients included, the mean age was 44.9±8.6 years and the male to female ratio was 2.5:1. Common clinical presentations were jaundice (100%), ascites (88.3%), hepatic encephalopathy (60%). The most common etiology for underlying CLD was alcohol (51.7%) followed by chronic hepatitis B (20%) and chronic hepatitis C (15%) infection. Alcohol hepatitis (40%) followed by hepatotropic viral infections (20%) and drug-induced liver injury (15%) were common identifiable precipitating agents. After a follow-up period of 4 weeks, 56 (46.6%) out of 120 patients died. The presence of sepsis, hyponatremia, renal failure, and coagulopathy was significantly associated with high mortality. Mortality was higher among patients having high Chronic liver failure consortium- acute on chronic liver failure (CLIF-ACLF) grade and closely related to the number of organ failures.
Conclusions: ACLF is a rapidly progressive syndrome in chronic liver disease patients, having high short-term mortality.
Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013 Jun;144(7):1426-37.
Wlodzimirow KA, Eslami S, Hanna A, Nieuwoudt M, Chamuleau RA. A systematic review on prognostic indicators of acute on chronic liver failure and their predictive value for mortality. Liver Int. 2013;33(1):40-52.
Sarin SK, Kumar A, Almeida JA, Chawla YK, Fan ST, Garg H, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int. 2009;3(1):269-82.
Sarin SK, Kedarisetty CK, Abbas Z, Amarapurkar D, Bihari C, Chan AC, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the Study of the Liver (APASL) 2014. Hepatol Int. 2014;8(4):453-71.
Mukherjee PS, Vishnubhatla S, Amarapurkar DN, Das K, Sood A, Chawla YK, et al. Etiology and mode of presentation of chronic liver diseases in India: A multi centric study. PLoS One. 2017;12(10):0187033.
Ray G, Ghoshal UC, Banerjee PK, Pal BB, Dhar K, Pal AK, et al. Aetiological spectrum of chronic liver disease in eastern India. Trop Gastroenterol. 2000;21(2):60-2.
Garg H, Kumar A, Garg V, Sharma P, Sharma BC, Sarin SK. Clinical profile and predictors of mortality in patients of acute-on-chronic liver failure. Dig Liver Dis. 2012;44(2):166-71.
Setiawan VW, Stram DO, Porcel J, Lu SC, Marchand L, Noureddin M. Prevalence of chronic liver disease and cirrhosis by underlying cause in understudied ethnic groups: The multiethnic cohort. Hepatology. 2016;64(6):1969-77.
Goldberg D, Ditah IC, Saeian K, Lalehzari M, Aronsohn A, Gorospe EC. Changes in the Prevalence of Hepatitis C Virus Infection, Nonalcoholic Steatohepatitis, and Alcoholic Liver Disease Among Patients With Cirrhosis or Liver Failure on the Waitlist for Liver Transplantation. Gastroenterology. 2017;152(5):1090-9.
Duseja A, Chawla YK, Dhiman RK, Kumar A, Choudhary N, Taneja S. Non-hepatic insults are common acute precipitants in patients with acute on chronic liver failure (ACLF). Dig Dis Sci. 2010;55(11):3188-92.
Khatun UF, Sayeed A, Hussain SMB, Paul S, Kawsar NM, Azad MAS. Etiological study of acute on chronic liver failure among patients admitted in Medicine ward in Chittagong Medical College Hospital. JAFMC Bangladesh. 2013;9(2):13.
Shalimar, Kumar D, Vadiraja PK, Nayak B, Thakur B, Das P, et al. Acute on chronic liver failure because of acute hepatic insults: Etiologies, course, extrahepatic organ failure and predictors of mortality. J Gastroenterol Hepatol. 2016;31(4):856-64.
Arroyo V, Moreau R, Kamath PS, Jalan R, Ginès P, Nevens F, et al. Acute-on-chronic liver failure in cirrhosis. Nat Rev Dis Primers. 2016;2:16041.
Hernaez R, Solà E, Moreau R, Ginès P. Acute-on-chronic liver failure: an update. Gut. 2017;66(3):541-53.
Sen S, Williams R, Jalan R. The pathophysiological basis of acute-on-chronic liver failure. Liver. 2002;22(2):5-13.
Shalimar, Saraswat V, Singh SP, Duseja A, Shukla A, Eapen CE, et al. Acute-on-chronic liver failure in India: The Indian National Association for Study of the Liver consortium experience. J Gastroenterol Hepatol. 2016;31(10):1742-9.
Rajoo A, Lim SG, Phyo WW, Tun T, Dan YY, Lee YM, et al. Acute-on-chronic liver failure in a multi-ethnic Asian city: A comparison of patients identified by Asia-Pacific Association for the Study of the Liver and European Association for the Study of the Liver definitions. World J Hepatol. 2017;9(28):1133-40.
Huang K, Hu JH, Wang HF, He WP, Chen J, Duan XZ, et al. Survival and prognostic factors in hepatitis B virus-related acute-on-chronic liver failure. World J Gastroenterol. 2011;17(29):3448-52.
Gawande A, Gupta GK, Gupta A, Wanjari SJ, Goel V, Rathore V, et al. Acute-on-Chronic Liver Failure: Etiology of Chronic and Acute Precipitating Factors and Their Effect on Mortality. J Clin Exp Hepatol. 2019;9(6):699-703.
Devarbhavi H, Choudhury AK, Sharma MK, Maiwall R, Mahtab M, Rahman S, et al. Drug-Induced Acute-on-Chronic Liver Failure in Asian Patients. Am J Gastroenterol. 2019;114(6):929-37.