In a recently prospective study (CANONIC) it has been shown that the patients without a prior history of acute decompensation, acute-on-chronic liver failure was characterized by higher mortality compared with acute-on-chronic liver failure in patients with a prior history of acute decompensation.
ACLF has been extensively evaluated in both Europe and Asia in the last decade. Sepsis play a major role as a acute insult in a compensated liver disease in the western countries whereas in the east the hepatitis B virus or hepatitis E virus results in the acute insult. PIRO concept with immune-paresis in ACLF is well accepted. CANIONIC study has shown more mortality in ACLF at 90 days. New concensus has also been made to classify ACLF as A , B or C depending on the type of acute insult. Mortality is also more as per number of organ failure occurs (1,2 or 3), so classifying ACLF as per organ failure is also justifyable.
Finally ACLF is now a establised entity with high mortality, it may emerge as severe entity in future as NAFLD related liver disease are increasing and any acute insult in the form of alcohol,drugs,viral hepatitis may result in severe liver disease.
ACLF is basically an acute insult on an already compromised chronic liver disease, the acute insult may be alcohol,drugs,virus, toxin or flare of the underlying chronic liver disease. Most are associated with sepsis further worsening the prognosis. The term came into being when patients were found to gradually develop ascites after an acute liver insult. These cases were found to harbour previously unrecognised chronic liver disease (many were NAFLD related) which made their prognosis worse.
The ACLF is a clinical syndrome manifesting as acute and severe hepatic derangements resulting from varied insults. This term was first used in 1995 to describe a condition in which two insults to liver are operating simultaneously, one of them being ongoing and chronic, and the other acute
I thank all for the responses.
I think, that rapid deterioration or “critically ill cirrhotic” could be regarded as acute decompensation and as acute-on-chronic liver failure (ACLF).
ACLF is potentially reversible, but acute decompensation could also be potentially reversible condition. ACLF usually results following a precipitating event (bacterial infection, GI bleeding, HBV etc.), and the AD develops because of the same events.
It is important to know, why one patient is tolerant to accelerating events, but others are not.
Excellent research CANONIC has given us the tool for stratification of risk for critically ill cirrhotic (CLIF-SOFA score).
Identification of risk defines early specific treatments and intensive management.
Response will depend on the hepatic reserve at the time of the acute attack (as different cirrhotics have different degrees of hepatic reserve) as well as the type of acute insult. In India Virus (esp hepatitis E) and drugs ( especially Antituberculos drugs) are important causes.
Dear Gautam.
How to explain poor prognosis in fulminant hepatic failure, when the patients had full hepatic reserve?
And how to estimate time of the insult prior to hospital admission?
Sincerely, Zmicer.
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