Clinical profile of patients with acute-on-chronic liver failure

Abstract

Introduction: Acute-on-chronic liver failure (ACLF) results from an acute insult superimposed on previously compensated chronic liver disease (CLD). Aim: To study the etiological factors and prognosis of patients with ACLF. Material and Methods: The study was carried out at Army hospital (R&R), New Delhi, from July 2010- June 2012. ACLF was diagnosed in patients presenting with jaundice (bilirubin-5 mg/dL) and coagulopathy (INR-1.5) who developed clinical ascites and/or encephalopathy within 4 weeks of jaundice. The etiologies of the underlying liver disease and precipitating factors were investigated. Results: The study included 122 patients of ACLF (M- 72, F50; mean age 40.06±9.73 years). The etiologies of underlying CLD were HBV [n=54 (44.3 %)], alcohol [n=31 (25.4 %)], autoimmune liver disease [n=7 (5.7 %)], HBV+alcohol [n=3 (2.5 %)]; 2 (1.6 %) each of HBV+HCV, HCV and Wilson's; 1 each of PBC and PSC and cryptogenic in 19 (15.6 %). The causes of acute decompensation were hepatotropic viruses in 59 (48.3 %) [HEV-36 (29.5 %), acute HBV/reactivation-20 (16.4 %); HAV-1 (0.8 %), HCV- 2 (1.6 %); alcohol in 12 (9.8 %), drugs in 19 (15.5 %), HCC in 1 (0.8 %) and unidentified in 31 (25.4 %). The 3-month mortality was 53 (43.4 %). Bilirubin, albumin, and clinical coagulopathy were significantly associated with mortality. APACHE II was more useful than CTP and MELD in predicting short-term mortality. On liver biopsy [n=41 (23-transjugular liver biopsies, 18-post mortem)], Type I pattern was significantly associated with poor prognosis. Conclusions: Hepatotrophic viruses were the commonest cause of acute decompensation. The 3-month mortality was 43.4 %. Bilirubin, albumin, clinical coagulopathy, APACHE II and type I histological pattern were significantly associated with mortality.