Skip to main content

Advertisement

Log in

Acute-on-Chronic Liver Failure: Can We Agree on a Definition?

  • Management of the Cirrhotic Patient (NS Reau and A Cardenas, Section Editors)
  • Published:
Current Hepatology Reports Aims and scope Submit manuscript

Abstract

Acute-on-chronic liver failure (ACLF) has recently received more recognition. It is a condition characterized by acute clinical deterioration in patients with chronic liver disease and is often associated with a precipitant event. It is a form of decompensated cirrhosis characterized by the presence of extrahepatic organ failure and high short-term mortality. Several definitions have been recently proposed for ACLF; however, larger prospective studies are still needed to refine our understanding of this new entity. This article explores the most recently proposed definitions, classification, and prognostic models of ACLF.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig 1

Similar content being viewed by others

References

Papers of particular interest, published recently, have been highlighted as: • Of importance •• Of major importance

  1. Asrani SK, Larson JJ, Yawn B, Therneau TM, Kim WR. Underestimation of liver-related mortality in the United States. Gastroenterology. 2013;145:375–82. e1-2.

    Article  PubMed Central  PubMed  Google Scholar 

  2. D'Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol. 2006;44:217–31.

    Article  PubMed  Google Scholar 

  3. Sarin SK, Kumar A, Almeida JA, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int. 2009;3:269–82. APASL definition of ACLF.

    Article  PubMed Central  PubMed  Google Scholar 

  4. Jalan R, Gines P, Olson JC, et al. Acute-on chronic liver failure. J Hepatol. 2012;57:1336–48. EASL/AASLD definition of ACLF.

    Article  PubMed  Google Scholar 

  5. Moreau R, Jalan R, Gines P, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology. 2013;144: 1426-37, 37 e1-9. CANONIC study: first multicenter, prospective, observational study in patients with acute-on-chronic liver failure.

  6. Bajaj JS, O'Leary JG, Reddy KR, et al. Survival in infection-related acute-on-chronic liver failure is defined by extrahepatic organ failures. Hepatology. 2014;60:250–6. North America Consortium for the Study of End-Stage Liver Disease (NACSELD) study: first North American study on ACLF. This study focuses on infection-related ACLF only.

    Article  PubMed  Google Scholar 

  7. Jalan R, Yurdaydin C, Bajaj JS, et al. Toward an improved definition of acute-on-chronic liver failure. Gastroenterology. 2014;147:4–10. Proposed definition for ACLF recently proposed on behalf of the World Gastroenterology Organization (WGO).

    Article  PubMed  Google Scholar 

  8. Kim TY, Kim DJ. Acute-on-chronic liver failure. Clin Mol Hepatol. 2013;19:349–59.

    Article  PubMed Central  PubMed  Google Scholar 

  9. Fernandez J, Navasa M, Gomez J, et al. Bacterial infections in cirrhosis: epidemiological changes with invasive procedures and norfloxacin prophylaxis. Hepatology. 2002;35:140–8.

    Article  PubMed  Google Scholar 

  10. Fernandez J, Acevedo J, Castro M, et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology. 2012;55:1551–61.

    Article  PubMed  Google Scholar 

  11. Arvaniti V, D'Amico G, Fede G, et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology. 2010;139:1246–56. 56 e1-5.

    Article  PubMed  Google Scholar 

  12. Foreman MG, Mannino DM, Moss M. Cirrhosis as a risk factor for sepsis and death: analysis of the National Hospital Discharge Survey. Chest. 2003;124:1016–20.

    Article  PubMed  Google Scholar 

  13. Kamath PS, Wiesner RH, Malinchoc M, et al. A model to predict survival in patients with end-stage liver disease. Hepatology. 2001;33:464–70.

    Article  CAS  PubMed  Google Scholar 

  14. Gines P, Schrier RW. Renal failure in cirrhosis. N Engl J Med. 2009;361:1279–90.

    Article  CAS  PubMed  Google Scholar 

  15. Martin-Llahi M, Guevara M, Torre A, et al. Prognostic importance of the cause of renal failure in patients with cirrhosis. Gastroenterology. 2011;140:488–96. e4.

    Article  PubMed  Google Scholar 

  16. Nadim MK, Genyk YS, Tokin C, et al. Impact of the etiology of acute kidney injury on outcomes following liver transplantation: acute tubular necrosis versus hepatorenal syndrome. Liver Transpl. 2012;18:539–48.

    Article  PubMed  Google Scholar 

  17. Akriviadis E, Botla R, Briggs W, Han S, Reynolds T, Shakil O. Pentoxifylline improves short-term survival in severe acute alcoholic hepatitis: a double-blind, placebo-controlled trial. Gastroenterology. 2000;119:1637–48.

    Article  CAS  PubMed  Google Scholar 

  18. Fernandez J, Navasa M, Planas R, et al. Primary prophylaxis of spontaneous bacterial peritonitis delays hepatorenal syndrome and improves survival in cirrhosis. Gastroenterology. 2007;133:818–24.

    Article  CAS  PubMed  Google Scholar 

  19. Wright G, Davies NA, Shawcross DL, et al. Endotoxemia produces coma and brain swelling in bile duct ligated rats. Hepatology. 2007;45:1517–26.

    Article  CAS  PubMed  Google Scholar 

  20. Harputluoglu MM, Demirel U, Gul M, et al. Effects of rifaximin on bacterial translocation in thioacetamide-induced liver injury in rats. Inflammation. 2012;35:1512–7.

    Article  CAS  PubMed  Google Scholar 

  21. Fernandez J, Escorsell A, Zabalza M, et al. Adrenal insufficiency in patients with cirrhosis and septic shock: effect of treatment with hydrocortisone on survival. Hepatology. 2006;44:1288–95.

    Article  CAS  PubMed  Google Scholar 

  22. Liu H, Lee SS. Acute-on-chronic liver failure: the heart and systemic hemodynamics. Curr Opin Crit Care. 2011;17:190–4.

    Article  PubMed  Google Scholar 

  23. Christou L, Pappas G, Falagas ME. Bacterial infection-related morbidity and mortality in cirrhosis. Am J Gastroenterol. 2007;102:1510–7.

    Article  PubMed  Google Scholar 

  24. Levesque E, Saliba F, Ichai P, Samuel D. Outcome of patients with cirrhosis requiring mechanical ventilation in ICU. J Hepatol. 2014;60:570–8.

    Article  CAS  PubMed  Google Scholar 

  25. Lisman T, Leebeek FW, de Groot PG. Haemostatic abnormalities in patients with liver disease. J Hepatol. 2002;37:280–7.

    Article  CAS  PubMed  Google Scholar 

  26. Lisman T, Bakhtiari K, Pereboom IT, Hendriks HG, Meijers JC, Porte RJ. Normal to increased thrombin generation in patients undergoing liver transplantation despite prolonged conventional coagulation tests. J Hepatol. 2010;52:355–61.

    Article  CAS  PubMed  Google Scholar 

  27. Montalto P, Vlachogiannakos J, Cox DJ, Pastacaldi S, Patch D, Burroughs AK. Bacterial infection in cirrhosis impairs coagulation by a heparin effect: a prospective study. J Hepatol. 2002;37:463–70.

    Article  CAS  PubMed  Google Scholar 

  28. Vincent JL, Yagushi A, Pradier O. Platelet function in sepsis. Crit Care Med. 2002;30:S313–7.

    Article  CAS  PubMed  Google Scholar 

  29. Jun CH, Park CH, Lee WS, et al. Antibiotic prophylaxis using third generation cephalosporins can reduce the risk of early rebleeding in the first acute gastroesophageal variceal hemorrhage: a prospective randomized study. J Korean Med Sci. 2006;21:883–90.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  30. Dunn W, Jamil LH, Brown LS, et al. MELD accurately predicts mortality in patients with alcoholic hepatitis. Hepatology. 2005;41:353–8.

    Article  PubMed  Google Scholar 

  31. Dunn W, Angulo P, Sanderson S, et al. Utility of a new model to diagnose an alcohol basis for steatohepatitis. Gastroenterology. 2006;131:1057–63.

    Article  PubMed Central  PubMed  Google Scholar 

  32. Monsanto P, Almeida N, Lrias C, Pina JE, Sofia C. Evaluation of MELD score and Maddrey discriminant function for mortality prediction in patients with alcoholic hepatitis. Hepatogastroenterology. 2013;60:1089–94.

    CAS  PubMed  Google Scholar 

  33. Louvet A, Naveau S, Abdelnour M, et al. The Lille model: a new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids. Hepatology. 2007;45:1348–54.

    Article  CAS  PubMed  Google Scholar 

  34. Teh SH, Nagorney DM, Stevens SR, et al. Risk factors for mortality after surgery in patients with cirrhosis. Gastroenterology. 2007;132:1261–9.

    Article  PubMed  Google Scholar 

  35. Kumar A, Saraswat VA. Hepatitis E and acute-on-chronic liver failure. J Clin Exp Hepatol. 2013;3:225–30.

    Article  PubMed Central  PubMed  Google Scholar 

  36. Singh KK, Panda SK, Shalimar, Acharya SK. Patients with diabetes mellitus are prone to develop severe hepatitis and liver failure due to hepatitis virus infection. J Clin Exp Hepatol. 2013;3:275–80.

    Article  PubMed Central  CAS  PubMed  Google Scholar 

  37. Graham DJ, Drinkard CR, Shatin D. Incidence of idiopathic acute liver failure and hospitalized liver injury in patients treated with troglitazone. Am J Gastroenterol. 2003;98:175–9.

    Article  CAS  PubMed  Google Scholar 

  38. Chalasani N, Fontana RJ, Bonkovsky HL, et al. Causes, clinical features, and outcomes from a prospective study of drug-induced liver injury in the United States. Gastroenterology. 2008;135:1924–34. 34 e1-4.

    Article  PubMed Central  PubMed  Google Scholar 

  39. Fromenty B. Drug-induced liver injury in obesity. J Hepatol. 2013;58:824–6.

    Article  PubMed  Google Scholar 

  40. Garg H, Sarin SK, Kumar M, Garg V, Sharma BC, Kumar A. Tenofovir improves the outcome in patients with spontaneous reactivation of hepatitis B presenting as acute-on-chronic liver failure. Hepatology. 2011;53:774–80.

    Article  CAS  PubMed  Google Scholar 

  41. Bahirwani R, Shaked O, Bewtra M, Forde K, Reddy KR. Acute-on-chronic liver failure before liver transplantation: impact on posttransplant outcomes. Transplantation. 2011;92:952–7.

    Article  PubMed  Google Scholar 

Download references

Compliance with Ethics Guidelines

Conflict of Interest

Douglas A. Simonetto and Patrick S. Kamath declare that they have no conflict of interest.

Human and Animal Rights and Informed Consent

This article does not contain any studies with human or animal subjects performed by any of the authors.

Author information

Authors and Affiliations

Authors

Corresponding author

Correspondence to Patrick S. Kamath.

Additional information

This article is part of the Topical Collection on Management of the Cirrhotic Patient

iThenticate: 17 % ok

Rights and permissions

Reprints and permissions

About this article

Check for updates. Verify currency and authenticity via CrossMark

Cite this article

Simonetto, D.A., Kamath, P.S. Acute-on-Chronic Liver Failure: Can We Agree on a Definition?. Curr Hepatology Rep 14, 40–45 (2015). https://doi.org/10.1007/s11901-015-0254-x

Download citation

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s11901-015-0254-x

Keywords

Navigation