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Etiology, clinical profile, and inhospital mortality of acute-on-chronic liver failure: a prospective study

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Abstract

Background

The causes of acute injury in acute-on-chronic liver failure (ACLF) are variable. There may be simultaneous presence of more than one acute insult. We describe the clinical profile of ACLF and the effect of dual acute insult on the natural history.

Methods

Patients with jaundice diagnosed to have ACLF were prospectively enrolled. Patients were evaluated for the clinical presentation, etiology of acute decompensation and underlying chronic liver disease, and inhospital mortality. We compared the clinical profile of patients who had dual acute insult with those of single/unknown insult.

Results

Fifty-two patients with ACLF (mean age 38.6±16.7 years; M/F 41:11) were included. Hepatitis virus infection (46.1 %) and bacterial infection (36.5 %) were the most common acute insults. Hepatitis virus infections were the sole acute insult in 34.6 % and associated with another injury in 11.5 %. Bacterial infections were identified as acute insult in 19 patients (sole acute insult in 13). Drugs, autoimmune disease, surgery, malaria, and dengue were other acute injuries identified. The cause of acute decompensation was unknown in 11.5 %. Mortality (66.6 % vs. 51.1 %) was higher in patients with dual insult (n=9) as compared with single/unknown insult (n=43).

Conclusions

Hepatitis virus and bacterial infection/sepsis were the common acute insults in ACLF. Dual acute insult is not uncommon, poses diagnostic dilemma, and may increase mortality in these patients. Plasmodium falciparum infection and dengue fever may be associated with ACLF.

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References

  1. 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.

    Article  PubMed  Google Scholar 

  2. Sen S, Williams R, Jalan R. The pathophysiological basis of acute-on-chronic liver failure. Liver. 2002;22 Suppl 2:5–13.

    PubMed  Google Scholar 

  3. Sen S, Davies NA, Mookerjee RP, et al. Pathophysiological effects of albumin dialysis in acute-on-chronic liver failure: a randomized controlled study. Liver Transpl. 2004;10:1109–19.

    Article  PubMed  Google Scholar 

  4. Laleman W, Wilmer A, Evenepoel P, et al. Effect of the molecular adsorbent recirculating system and Prometheus devices on systemic haemodynamics and vasoactive agents in patients with acute-on-chronic alcoholic liver failure. Crit Care. 2006;10:R108.

    Article  PubMed  Google Scholar 

  5. Cui YL, Yan F, Wang YB, et al. Nucleoside analogue can improve the long-term prognosis of patients with hepatitis B virus infection-associated acute on chronic liver failure. Dig Dis Sci. 2010;55:2373–80.

    Article  PubMed  CAS  Google Scholar 

  6. Yu JW, Sun LJ, Zhao YH, Li SC. Prediction value of model for end-stage liver disease scoring system on prognosis in patients with acute-on-chronic hepatitis B liver failure after plasma exchange and lamivudine treatment. J Gastroenterol Hepatol. 2008;23:1242–9.

    Article  PubMed  CAS  Google Scholar 

  7. Acharya SK, Sharma PK, Singh R, et al. Hepatitis E virus (HEV) infection in patients with cirrhosis is associated with rapid decompensation and death. J Hepatol. 2007;46:387–94.

    Article  Google Scholar 

  8. Kumar M, Sharma BC, Sarin SK. Hepatitis E virus as an etiology of acute exacerbation of previously unrecognized asymptomatic patients with hepatitis B virus-related chronic liver disease. J Gastroenterol Hepatol. 2008;23:883–7.

    Article  PubMed  Google Scholar 

  9. Radha Krishna Y, Saraswat VA, Das K, et al. Clinical features and predictors of outcome in acute hepatitis A and hepatitis E virus hepatitis on cirrhosis. Liver Int. 2009;29:392–8.

    Article  PubMed  Google Scholar 

  10. Ramachandran J, Eapen CE, Kang G, et al. Hepatitis E super-infection produces severe decompensation in patients with chronic liver disease. J Gastroenterol Hepatol. 2004;19:134–8.

    Article  PubMed  Google Scholar 

  11. Kumar A, Aggarwal R, Naik SR, Saraswat V, Ghoshal UC, Naik S. Hepatitis E virus is responsible for decompensation of chronic liver disease in an endemic region. Indian J Gastroenterol. 2004;23:59–62.

    PubMed  Google Scholar 

  12. Monga R, Garg S, Tyagi P, Kumar N. Superimposed acute hepatitis E infection in patients with chronic liver disease. Indian J Gastroenterol. 2004;23:50–2.

    PubMed  Google Scholar 

  13. Mahtab MA, Rahman S, Khan M, Karim MF. Hepatitis E virus is a leading cause of acute-on-chronic liver disease: experience from a tertiary centre in Bangladesh. Hepatob Pancreat Dis Int. 2009;8:50–2.

    Google Scholar 

  14. Duseja A, Chawla YK, Dhiman RK, Kumar A, Choudhary N, Taneja S. Non-hepatic insults are common acute precipitants in patients with acute on chronic liver failure (ACLF). Dig Dis Sci. 2010;55:3188–92.

    Article  PubMed  Google Scholar 

  15. Rajneesh AR, Rangan K, Thomas V. Acute on chronic liver failure. Calicut Med J. 2011;9:e6.

    Google Scholar 

  16. El Sayed Zaki M, Othman W. Role of hepatitis E infection in acute on chronic liver failure in Egyptian patients. Liver Int. 2011;31:1001–5.

    Article  PubMed  Google Scholar 

  17. Jha AK, Nijhawan S, Suchismita A. Sepsis in acute on chronic liver failure. Dig Dis Sci. 2011;56:1245–6.

    Article  PubMed  Google Scholar 

  18. Jalan R, Williams R. Acute-on-chronic liver failure: pathophysiological basis of therapeutic options. Blood Purif. 2002;20:252–61.

    Article  PubMed  Google Scholar 

  19. Gustot T, Durand F, Lebrec D, Vincent JL, Morea R. Severe sepsis in cirrhosis. Hepatology. 2009;50:2022–33.

    Article  PubMed  CAS  Google Scholar 

  20. Wasmuth HE, Kunz D, Yagmur E, et al. Patients with acute on chronic liver failure display “sepsis-like” immune paralysis. J Hepatol. 2005;42:195–201.

    Article  PubMed  CAS  Google Scholar 

  21. Katoonizadeh A, Laleman W, Verslype C, et al. Early features of acute-on-chronic alcoholic liver failure: a prospective cohort study. Gut. 2010;59:1561–9.

    Article  PubMed  Google Scholar 

  22. Mookerjee RP, Stadlbauer V, Lidder S, et al. Neutrophil dysfunction in alcoholic hepatitis superimposed on cirrhosis is reversible and predicts outcome. Hepatology. 2007;46:831–40.

    Article  PubMed  CAS  Google Scholar 

  23. Chung RT, Friedman LS. Bacterial, parasitic, and fungal infections of the liver, including liver abscess. In: Feldman M, Friedman LS, Brandt LJ, eds. Sleisenger and Fordtran's Gastrointestinal and Liver Disease. 8th ed. Philadelphia: Saunders; 2006. p. 1731.

  24. Deepak NA, Patel ND. Differential diagnosis of acute liver failure in India. Ann Hepatol. 2006;5:150–6.

    Google Scholar 

  25. Mudawi HM, Yousif BA. Fulminant hepatic failure in an African setting: etiology, clinical course, and predictors of mortality. Dig Dis Sci. 2007;52:3266–9.

    Article  PubMed  CAS  Google Scholar 

  26. Devarbhavi H, Alvares JF, Kumar KS. Severe falciparum malaria simulating fulminant hepatic failure. Mayo Clin Proc. 2005;80:355–8.

    Article  PubMed  Google Scholar 

  27. Ghoshal UC, Somani S, Chetri K, Akhtar P, Aggarwal R, Naik SR. Plasmodium falciparum and hepatitis E virus co-infection in fulminant hepatic failure. Indian J Gastroenterol. 2001;20:111.

    PubMed  CAS  Google Scholar 

  28. Osorio J, Carvajal C, Sussman O, Buitrago R, Franco-Paredes C. Acute liver failure due to dengue virus infection. Int J Infect Dis. 2008;12:444–5.

    Article  PubMed  Google Scholar 

  29. Itha S, Kashyap R, Krishnani N, Saraswat VA, Choudhuri G, Aggarwal R. Profile of liver involvement in dengue virus infection. Natl Med J India. 2005;18:127–30.

    PubMed  Google Scholar 

  30. Vinodh BN, Bammigatti C, Kumar A, Mittal V. Dengue fever with acute liver failure. J Postgrad Med. 2005;51:322–3.

    PubMed  CAS  Google Scholar 

  31. Souza LJ, Coelho JM, Silva EJ, et al. Acute hepatitis due to dengue virus in a chronic hepatitis patient. Braz J Infect Dis. 2008;12:456–9.

    Article  PubMed  CAS  Google Scholar 

  32. Gharsangi K. Dengue causing fulminant hepatitis in a hepatitis B virus carrier. Biosci Trends. 2011;5:44–5.

    Article  PubMed  Google Scholar 

  33. Carvalho de Macedo F, Nicol AF, Cooper LD, et al. Histologic, viral, and molecular correlates of dengue fever infection of the liver using highly sensitive immunohistochemistry. Diagn Mol Pathol. 2006;15:223–8.

    Article  Google Scholar 

  34. Couvelard A, Marianneau P, Bedel C, et al. Report of a fatal case of dengue infection with hepatitis: demonstration of dengue antigens in hepatocytes and liver apoptosis. Hum Pathol. 1999;30:1106–10.

    Article  PubMed  CAS  Google Scholar 

  35. Alcon-LePoder S, Drouet MT, Roux P, et al. The secreted form of dengue virus nonstructural protein NS1 is endocytosed by hepatocytes and accumulates in late endosomes: implications for viral infectivity. J Virol. 2005;79:11403–11.

    Article  PubMed  CAS  Google Scholar 

  36. Vázquez-Pichardoa M, Rosales-Jiménezb C, Rojas-Espinosaa O, López-Martínezb I, Moreno-Altamirano MMB. Is liver damage dependent on the serotype of dengue virus?—a study in Mexico. Dengue Bull. 2006;30:114–20.

    Google Scholar 

  37. Kato H, Ikeuchi H, Nakamura M. Acute exacerbation of liver disease induced by pegylated interferon alpha2a treatment for chronic hepatitis C. Int J Clin Med. 2010;1:1–5.

    Article  CAS  Google Scholar 

  38. Kogure T, Ueno Y, Fukushima K, et al. Fulminant hepatic failure in a case of autoimmune hepatitis in hepatitis C during peg-interferon-alpha 2b plus ribavirin treatment. World J Gastroenterol. 2007;13:4394–7.

    PubMed  CAS  Google Scholar 

  39. Mao Q, Zhang HY, You JP, Zhang XQ. Severe acute exacerbation of chronic hepatitis B during pegylated interferon treatment and early intervention with corticosteroid. Virol J. 2012;9:136.

    Article  PubMed  CAS  Google Scholar 

  40. Ripoll C, Groszmann R, Garcia-Tsao G, Portal Hypertension Collaborative Group, et al. Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis. Gastroenterology. 2007;133:481–8.

    Google Scholar 

  41. Jalan R, Gines P, Olson JC, et al. Acute-on chronic liver failure. J Hepatol. 2012; 57:1336–48.

    Google Scholar 

  42. Khuroo MS, Khuroo MS, Farahat KL. Molecular adsorbent recirculating system for acute and acute-on-chronic liver failure: a meta-analysis. Liver Transpl. 2004;10:1099–106.

    Google Scholar 

  43. Chan AC, Fan ST, Lo CM, et al. Liver transplantation for acute-on-chronic liver failure. Hepatol Int. 2009;3:571–81.

    Google Scholar 

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Acknowledgments

We thank Ms. Prakriti Sinha for the help regarding statistical analysis.

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Authors and Affiliations

  1. Department of Gastroenterology, Sawai Man Singh Medical College, Jaipur, 302 004, India

    Ashish Kumar Jha, Sandeep Nijhawan, Ramesh Roop Rai, Subhash Nepalia, Pankaj Jain & Arya Suchismita

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  1. Ashish Kumar Jha
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  2. Sandeep Nijhawan
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Correspondence to Sandeep Nijhawan.

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Jha, A.K., Nijhawan, S., Rai, R.R. et al. Etiology, clinical profile, and inhospital mortality of acute-on-chronic liver failure: a prospective study. Indian J Gastroenterol 32, 108–114 (2013). https://doi.org/10.1007/s12664-012-0295-9

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  • DOI: https://doi.org/10.1007/s12664-012-0295-9

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