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Acute-on-Chronic Liver Failure

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Liver Immunology

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Abstract

Acute-on-chronic liver failure (ACLF) is a severe form of liver disease and a distinct syndrome in patient with diagnosed or undiagnosed chronic liver disease and manifests as jaundice, coagulopathy, and ascites and/or hepatic encephalopathy, secondary to acute hepatic insult and associated with increased 28-day mortality. There is a controversy in the definition of ACLF, and there is East and West conflict regarding the same. There is lack of consensus globally; however, the syndrome is different from patients with acute liver failure and those with end-stage liver disease. The acute insult sets in the cytokine storm leading to systemic inflammatory response syndrome (SIRS) and/or leading to immunoparalysis, predisposing to sepsis and organ failure. There is a concept of period of “7 days” known as golden window during which the patient should be aggressively managed and listed for transplant if required. Preventing sepsis, organ support and management of organ failure (commonly hepatic, renal, cerebral, coagulation), and early transplant referral is utmost important. Multiple prognostic scores have been proposed. The AARC (APASL ACLF research consortium) score is a dynamic score and is a prognostic model for guiding management decisions and is found to be superior. Multidisciplinary approach and exploring new therapeutics can lead to a transplant-free survival in nearly half of the cases. This chapter provides an approach to organ failure management, prevention, and management of sepsis, assessing the various prognostic models for guiding the management and improving the outcomes of ACLF patients.

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Abbreviations

AARC:

APASL ACLF research consortium

ACLF:

Acute-on-chronic liver failure

AD:

Acute decompensation

AIH:

Autoimmune hepatitis

APACHE:

Acute Physiology and Chronic Health Evaluation

APASL:

Asian Pacific Association for the Study of the Liver

CANONIC-CLIF:

Acute-on-chronic liver failure in cirrhosis

DAMPs:

Damage-associated molecular patterns

EASL-CLIF:

European Association for the Study of the Liver Chronic Liver Failure consortium

HE:

Hepatic encephalopathy

MELD:

Model for end-stage liver disease

ROS:

Reactive oxygen species

SIRS:

Systemic inflammatory response syndrome

SOFA:

Sequential organ failures assessment

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Authors and Affiliations

  1. Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India

    Vinod Arora, Rakesh Kumar Jagdish & Shiv Kumar Sarin

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  1. Vinod Arora
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  2. Rakesh Kumar Jagdish
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Editors and Affiliations

  1. Division of Rheumatology, Allergy and Clinical Immunology, The University of California School of Medicine, Davis, CA, USA

    M. Eric Gershwin

  2. Departments of Medicine and Surgery, Baylor College of Medicine, Houston, TX, USA

    John M. Vierling

  3. Department of Medicine, Teikyo University School of Medicine, Itabashi, Tokyo, Japan

    Atsushi Tanaka

  4. President, Hannover Medical School, Hannover, Germany

    Michael P. Manns

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Arora, V., Jagdish, R.K., Sarin, S.K. (2020). Acute-on-Chronic Liver Failure. In: Gershwin, M.E., M. Vierling, J., Tanaka, A., P. Manns, M. (eds) Liver Immunology . Springer, Cham. https://doi.org/10.1007/978-3-030-51709-0_32

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