A study of clinical profile and factors affecting mortality in patients with acute on chronic liver failure in a tertiary hospital in north east India
DOI:
https://doi.org/10.18203/2320-6012.ijrms20210446Keywords:
Acute chronic liver failure, Chronic liver disease, Organ failure, MELDAbstract
Background: Data regarding Acute on Chronic Liver Failure (ACLF) patients from North East India is scarce and presentation to hospital is often late. We aim to study their clinical profile, aetiology of underlying chronic liver disease, precipitating factors, predictors of mortality and their short term outcome (3 months).
Methods: Among 1000 consecutive patients of any form of acute decompensation, 245 patients diagnosed as ACLF were prospectively studied. Comparison was done between survivors versus non survivors of ACLF and between ACLF and Non ACLF patients.
Results: Mean age of ACLF patients was 44.2±10.3 years and male:female ratio was 13.4:1. Common causes of underlying cirrhosis in ACLF was alcoholic liver disease, 210 (85.7%), Hepatitis B virus related cirrhosis, 20 (8.2%), Hepatitis C virus related cirrhosis, 6 (2.4%) and cryptogenic in 8 (3.3%). Precipitating causes were alcoholic hepatitis in 98 (46.6%) among alcoholic cirrhosis, acute flare of Hepatitis B infection in 12 patients (60%) among Hepatitis B related cirrhosis, recent use of drugs in 110 (44.8%), sepsis in 71 (28.9%), spontaneous bacterial peritonitis (SBP) in 36 (14.7%), urinary tract infection in 36 (14.7%), acute hepatitis A in 5 (2%) and acute hepatitis E in 3 (1.2%). hepatic encephalopathy, low sodium, high International Normalised Ratio (INR) were found to be significantly associated with high mortality. Increasing number of organ failures is associated with increasing risk of death.
Conclusions: ACLF is characterized by rapid deterioration especially when multiorgan failure sets in due to certain precipitating factors in a previously diagnosed or undiagnosed chronic liver disease.
References
Ohnishi H, Sugihara J, Moriwaki H, Muto Y. Acute-on-chronic-liver failure. Ryoikibetsu Shokogun Shirizu. 1995;(7):217-9.
Sarin SK, Kumar A, Almeida JA. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int. 2009;3:269-82.
Moreau R, Jalan R, Gines P. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144(7):1426-37.
Laleman W, Wilmer A, Evenepoel P, Elst IV, Zeegers M, Zaman Z, et al. Effect of the molecular adsorbent recirculating system and Prometheus devices on systemic haemodynamics and vasoactive agents in patients with acute on- chronic alcoholic liver failure. Crit Care. 2006;10(4):R108.
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.
Moreau R, Gines P, Jalan R. Diagnosis, prevalence, and prognosis of acute-on-chronic liver failure (ACLF): results of the EASL Indian chronic liver failure (CLIF) consortium canonic study. J Hepatol. 2012;56:552-3.
Kohrt HE, Ouyang DL, Keeffe EB. Antiviral prophylaxis for chemotherapy induced reactivation of chronic hepatitis B virus infection. Clin Liver Dis. 2007;11:965-91.
Sera T, Hiasa Y, Michitaka K, Konishi I, Matsuura K, TokumotoY, et al. Anti-HBs-positive liver failure due to hepatitis B virus reactivation induced by rituximab. Intern Med. 2006;45:721-4.
Hamid SS, Atiq M, Shehzad F, Yasmeen A, Nissa T, Salam A, Siddiqui A, Jafri W. Hepatitis E virus superinfection in patients with chronic liver disease. Hepatology. 2002;36:474-8.
Kumar AS, Kumar SP, Singh R, Kumar MS, Madan K, Kumar JJ, et al. Hepatitis E virus (HEV) infection in patients with cirrhosis is associated with rapid decompensation and death. J Hepatol. 2007;46:387-94.
Kumar A, Aggarwal R, Naik SR, Sarawat V, Ghoshal UC, Naik S. Hepatitis E virus is responsible for decompensation of chronic liver disease in an endemic region. Indian J Gastroenterol. 2004;23:59-62.
Lee KH, Lee MK, Sutedja DS, Lim SG. Outcome from molecular adsorbent recycling system (MARS) liver dialysis following drug-induced liver failure. Liver Int. 2005;25:973-7.
Mattéi A, Rucay P, Samuel D, Feray C, Reynes M, Bismuth H. Liver transplantation for severe acute liver failure after herbal medicine (Teucrium polium) administration. J Hepatol. 1995;22:597.
Detsky AS, McLaughlin JR, Baker JP, Johnston N. What is subjective global assessment of nutritional status? J Parenter Nutr. 1987;11(1):8-13.
Makhija S, Baker J. The subjective global assessment : a review of its use in clinical practice. Nutr Clin Prac. 2008;23(4):405-9.
Sen S, Williams R, Jalan R. The patho physiological basis of acute-on-chronic liver failure. Liver. 2002;22(2):5-13.
Khatun UF, Sayeed A, Hussain SMB, Paul S, Kawsar NM, Al-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.
Pati GK. Acute-on-chronic liver failure (ACLF) in coastal eastern India a single-center experience. J Clin Exp Hepatol. 2015;6:76-9.
Zauner C, Schneeweiss B, Schneider B. Short-term prognosis in critically ill patients with liver cirrhosis: an evaluation of a new scoring system. Eur J Gastroenterol Hepatol. 2000;12:517-22.
Zauner CA, Apsner RC, Kranz A. Outcome prediction for patients with cirrhosis of the liver in a medical ICU: a comparison of the APACHE scores and liver-specific scoring systems. Intensive Care Med. 1996;22:559-63.
Rabe C, Schmitz V, Paashaus M. Does intubation really equal death in cirrhotic patients? Factors influencing outcome in patients with liver cirrhosis requiring mechanical ventilation. Intensive Care Med. 2004;30:1564-71.
Aggarwal A, Ong JP, Younossi ZM. Predictors of mortality and resource utilization in cirrhotic patients admitted to the medical ICU. Chest. 2001;119:1489-97.
Gildea TR, Cook WC, Nelson DR. Predictors of long-term mortality in patients with cirrhosis of the liver admitted to a medical ICU. Chest. 2004;126:1598-603.
Tsai MH, Peng YS, Lien JM. Multiple organ system failure in critically ill cirrhotic patients a comparison of two multiple organ dysfunction/failure scoring systems. Digestion. 2004;69:190-200.
Singh N, Gayowski T, Wagener MM. Outcome of patients with cirrhosis requiring intensive care unit support: prospective assessment of predictors of mortality. J Gastroenterol. 1998;33:73-9.
Bhattacharyya M, Barman NN. Clinical profile of Cirrhosis of liver in a tertiary care Hospital of Assam, North East India. J Dental Med Sci. 2016;15:21-7.
Garg H, Kumar A, Garg V. Clinical profile and predictors of mortality in patients of acute-on-chronic liver failure. Dig Liver Dis. 2012;44:166-71.
Singh N, Gayowski T, Wagener MM. Outcome of patients with cirrhosis requiring intensive care unit support: prospective assessment of predictors of mortality. J Gastroenterol. 1998;33:73-9.
Sen S, Davies NA, Mookerjee RP, et al. Pathophysiological effects of albumin dialysis in acute-on-chronic liver failure: a randomized controlled study. Liver Transpl. 2004;10:1109-19.
Wehler M, Kokoska J, Reulbach U. Short-term prognosis in critically ill patients with cirrhosis assessed by prognostic scoring systems. Hepatol. 2001;34:255-61.
Heemann U, Treichel U, Loock J. Albumin dialysis in cirrhosis with superimposed acute liver injury: a prospective, controlled study. Hepatol. 2002;36:949-58.
Dhiman RK, Agrawal S, Gupta T. Chronic liver failure- sequential organ failure assessment is better than the asia-pacific association for the study of liver criteria for defining acute-on-chronic liver failure and predicting outcome. World J Gastroenterol. 2014;20(40):14934-41.
Wasmuth HE, Kunz D, Yagmur E, Stranghoner A, Vidacek D, Siewert E, et al. Patients with acute on chronic liver failure display ‘‘sepsis-like’’ immune paralysis. J Hepatol. 2005;42:195-201.
Das AK, Begum T, Kar P. Profile of acute liver failure from North east India and its differences from other parts of the country. Euroasian J Hepatogastroenterol. 2016;6(2):111-5.
Kumar R, Rahul D, Prabhakar B. A study of clinical profile in patients with acute on chronic liver failure in a tertiary hospital. Asian Pac J Health Science. 2016;3(2):47-57.
Amrapurkar D, Dharod V, Mrudul D. Acute on chronic liver failure: a prospective study to determine the clinical profile, outcome and factors predicting mortality, Ind J Gastroenterol. 2015;34(3):216-24.
Cholongitas E, Senzolo M, Patch D. Risk factors, sequential organ failure assessment and model for end-stage liver disease scores for predicting short term mortality in cirrhotic patients admitted to intensive care unit. Aliment Pharmacol Ther. 2006;23:883-93.
