Abstract
Acute on chronic liver failure is an entity distinct from acute liver failure and acute decompensation of chronic liver disease. Despite best medical therapy, it is associated with high short-term mortality due to infection and organ failure. Liver transplantation is a potentially curative treatment option that has been shown to have good outcomes in this setting. As there are no reliable ways of predicting which subset of patients will recover spontaneously, early transplantation before establishment of full blown sepsis or organ failure is expected to have favorable outcomes with an acceptable risk. This article reviews current literature on liver transplantation for acute on chronic liver failure, discusses challenges in patient selection, and proposes an algorithm for management.
Similar content being viewed by others
References
Ohnishi H, Sugihara J, Moriwaki H, Muto Y. Acute-on-chronic liver failure. Ryoikibetsu Shokogun Shirizu 1995;7:217–219
Wlodzimirow KA, Eslami S, Abu-Hanna A, Nieuwoudt M, Chamuleau RA. A systematic review on prognostic indicators of acute on chronic liver failure and their predictive value for mortality. Liver Int 2013;33:40–52
Sarin SK, Kumar A, Almeida JA, Chawla YK, Fan ST, Garg H, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int 2009;3:269–282
Jalan R, Gines P, Olson JC, Mookerjee RP, Moreau R, Garcia-Tsao G, et al. Acute-on-chronic liver failure. European Association for the study of the liver. J Hepatol 2012;57:1336–1348
Bernal W, Hyyrylainen A, Gera A, Audimoolam VK, McPhail MJ, Auzinger G, et al. Lessons from look-back in acute liver failure? A single centre experience of 3300 patients. J Hepatol 2013;59:74–80
Moreau R, Jalan R, Gines P, Pavesi M, Angeli P, Cordoba J, et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013;144:1426–1437, 1437.e1–1437.e9
Chen JF, Wang KW, Zhang SQ, Lei ZY, Xie JQ, Zhu JY, et al. Dexamethasone in outcome of patients with hepatitis B virus-related acute-on-chronic liver failure. J Gastroenterol Hepatol 2014;29:800–806
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;53:774–780
Xu X, Liu X, Ling Q, Wei Q, Liu Z, Xu X, et al. Artificial liver support system combined with liver transplantation in the treatment of patients with acute-on-chronic liver failure. PLoS ONE 2013;8:e58738
Finkenstedt A, Nachbaur K, Zoller H, Joannidis M, Pratschke J, Graziadei IW, et al. Acute-on-chronic liver failure: excellent outcomes after liver transplantation but high mortality on the wait list. Liver Transpl 2013;19:879–886
McPhail MJ, Wendon JA, Bernal W. Meta-analysis of performance of Kings’s College Hospital Criteria in prediction of outcome in non-paracetamol-induced acute liver failure. J Hepatol 2010;53:492–499
Ahmed A, Keeffe EB. Current indications and contraindications for liver transplantation. Clin Liver Dis 2007;11:227–247
Chan AC, Fan ST, Lo CM, Liu CL, Chan SC, Ng KK, et al. Liver transplantation for acute-on-chronic liver failure. Hepatol Int 2009;3:571–581
Ling Q, Xu X, Wei Q, Liu X, Guo H, Zhuang L, et al. Downgrading MELD Improves the outcomes after liver transplantation in patients with acute-on chronic hepatitis B liver failure. PLoS ONE 2012;7:e30322. doi:10.1371/journal.pone.0030322
Bahirwani R, Shaked O, Bewtra M, Forde K, Reddy KR. Acute-on-chronic liver failure before liver transplantation: impact on post transplant outcomes. Transplantation 2011;92:952–957
Duan BW, Lu SC, Wang ML, Liu JN, Chi P, Lai W, et al. Liver transplantation in acute-on-chronic liver failure patients with high model for end-stage liver disease (MELD) scores: a single center experience of 100 consecutive cases. J Surg Res 2013;183:936–943
Xing T, Zhong L, Chen D, Peng Z. Experience of combined liver–kidney transplantation for acute-on-chronic liver failure patients with renal dysfunction. Transpl Proc 2013;45:2307–2313
Lin KH, Liu JW, Chen CL, Wang SH, Lin CC, Liu YW, et al. Impacts of pretransplant infections on clinical outcomes of patients with acute-on-chronic liver failure who received living-donor liver transplantation. PLoS ONE 2013;8:e72893. doi:10.1371/journal.pone.0072893
Angeli P, Rodríguez E, Piano S, Ariza X, Morando F, Solà E, et al. Acute kidney injury and acute-on-chronic liver failure classifications in prognosis assessment of patients with acute decompensation of cirrhosis. Gut 2014. doi:10.1136/gutjnl-2014-307526
Garg H, Kumar A, Garg V, Kumar M, Kumar R, Sharma BC, et al. Hepatic and systemic hemodynamic derangements predict early mortality and recovery in patients with acute-on-chronic liver failure. J Gastroenterol Hepatol 2013;28:1361–1367
Katoonizadeh A, Laleman W, Verslype C, Wilmer A, Maleux G, Roskams T, et al. Early features of acute-on-chronic alcoholic liver failure: a prospective cohort study. Gut 2010;59:1561–1569
Gustot T, Fernandez J, Garcia E, Morando F, Caraceni P, Alessandria C, et al. Clinical course of acute-on-chronic liver failure syndrome and effects on prognosis. Hepatology 2015. doi:10.1002/hep.27849
Bajaj JS, O’Leary JG, Reddy KR, Wong F, Biggins SW, Patton H, et al. Survival in infection-related acute-on-chronic liver failure is defined by extrahepatic organ failures. Hepatology 2014;60:250–256
Bañares R, Nevens F, Larsen FS, Jalan R, Albillos A, Dollinger M, et al. Extracorporeal albumin dialysis with the molecular adsorbent recirculating system in acute-on-chronic liver failure: the RELIEF trial. Hepatology 2013;57:1153–1162
Jalan R, Stadlbauer V, Sen S, Cheshire L, Chang YM, Mookerjee RP. Role of predisposition, injury, response and organ failure in the prognosis of patients with acute-on-chronic liver failure: a prospective cohort study. Crit Care. 2012;27(16):R227
Romero-Gómez M, Montagnese S, Jalan R. Hepatic encephalopathy in patients with acute decompensation of cirrhosis and acute on chronic liver failure. J Hepatol 2015;62:437–447
Wehler M, Kokoska J, Reulbach U, Hahn EG, Strauss R. Short-term prognosis in critically ill patients with cirrhosis assessed by prognostic scoring systems. Hepatology 2001;34:255–261
Wasmuth HE, Kunz D, Yagmur E, Timmer-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
Berres ML, Schnyder B, Yagmur E, Inglis B, Stanzel S, Tischendorf JJ, et al. Longitudinal monocyte human leukocyte antigen-DR expression is a prognostic marker in critically ill patients with decompensated liver cirrhosis. Liver Int 2009;29:536–543
Kumar R, Krishnamoorthy TL, Tan HK, Lui HF, Chow WC. Change in model for end-stage liver disease score at two weeks, as an indicator of mortality or liver transplantation at 60 days in acute-on-chronic liver failure. Gastroenterol Rep (Oxf) 2015;3:122–127
Jalan R, Saliba F, Pavesi M, Amoros A, Moreau R, Ginès P, et al. Development and validation of a prognostic score to predict mortality in patients with acute-on-chronic liver failure. J Hepatol 2014;61:1038–1047
Arroyo V, Moreau R, Jalan R, Ginès P, EASL-CLIF Consortium CANONIC Study. Acute-on-chronic liver failure: a new syndrome that will re-classify cirrhosis. J Hepatol 2015;62:S131–S143
Jalan R, Pavesi M, Saliba F, Amorós A, Fernandez J, Holland-Fischer P, et al. The CLIF Consortium Acute Decompensation score (CLIF-C ADs) for prognosis of hospitalised cirrhotic patients without acute-on-chronic liver failure. J Hepatol 2015;62:831–840
Asrani SK, O’Leary JG. Acute on chronic liver failure. Clin Liver Dis 2014;18:561–574
Nadim MK, Sung RS, Davis CL, Andreoni KA, Biggins SW, Danovitch GM, et al. Simultaneous liver–kidney transplantation summit: current state and future directions. Am J Transpl 2012;12:2901–2908
Jalan R, Yurdaydin C, Bajaj JS, Acharya SK, Arroyo V, Lin HC, et al. Toward an improved definition of acute-on-chronic liver failure. Gastroenterology 2014;147:4–10
Testino G. Alcoholic hepatitis. J Med Life 2013;6:161–167
Mathurin P, Moreno C, Samuel D, Dumortier J, Salleron J, Durand F, et al. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med 2011;365:1790–1800
Compliance with ethical requirements and Conflict of interest
As this is a review article, there were no human subjects involved and hence there is no question of informed consent. All authors affirm that they did not receive any grants/ funding to write the manuscript. They declare no potential conflicts of interest (financial or non-financial).
Author information
Authors and Affiliations
Corresponding author
Rights and permissions
About this article
Cite this article
Pamecha, V., Kumar, S. & Bharathy, K.G.S. Liver transplantation in acute on chronic liver failure: challenges and an algorithm for patient selection and management. Hepatol Int 9, 534–542 (2015). https://doi.org/10.1007/s12072-015-9646-9
Received:
Accepted:
Published:
Issue Date:
DOI: https://doi.org/10.1007/s12072-015-9646-9