Increased Survival for Patients With Cirrhosis and Organ Failure in Liver Intensive Care and Validation of the Chronic Liver Failure–Sequential Organ Failure Scoring System

Introduction. Acute Physiology and Chronic Health Evaluation (APACHE) II and III and Sequential Organ Failure Assessment (SOFA) are prognostic scores commonly used in the intensive care unit (ICU). Their accuracy in predicting mortality has not been adequately evaluated in comparison to prognostic scores commonly used in critically ill cirrhotic patients with acute decompensation (AD) or acute-on-chronic liver failure (ACLF). Aims. This study was conducted to evaluate the performance of prognostic scores, including APACHE II, SOFA, Chronic Liver Failure Consortium (CLIF-C) SOFA, Child–Turcotte–Pugh (CPS), Model for End-Stage Liver Disease (MELD), MELD-Na, MELD to serum sodium ratio (MESO) index, CLIF-C organ failure (CLIF-C OF), CLIF-C ACLF, and CLIF-C AD scores, in predicting mortality of cirrhotic patients admitted to the ICU. Patients and Methods. A total of 382 patients (280 males, mean age 67.3 ± 10.6 years) with cirrhosis were retrospectively evaluated. All prognostic scores were calculated in the first 24 hours of ICU admission. Their ability to predict mortality was measured using the analysis of the area under the receiver operating characteristic curve (AUC). Results. Mortality was observed in 31% of the patients. Analysis of AUC revealed that CLIF-C OF (0.807) and CLIF-SOFA (0.776) had the best ability to predict mortality in all patients, but CLIF-C OF (0.749) had higher prognostic accuracy in patients with ACLF. CLIF-SOFA, SOFA, and CLIF-C AD had the highest AUC values in patients with AD, with no statistical difference ( p = 0.971 ). Conclusions. When compared to other general or liver-specific prognostic scores, CLIF-C OF, CLIF-SOFA, SOFA, and CLIF-C AD have good accuracy to predict mortality in critically ill patients with cirrhosis and patients with AD. According to the clinical scenario, different scores should be used to provide prognosis to patients with cirrhosis in the ICU.

Download Full-text

Pre‐transplant intensive care unit management and selection of grade 3 acute‐on‐chronic liver failure transplant candidates

Liver Transplantation ◽

10.1002/lt.26280 ◽

2021 ◽

Author(s):

Baptiste Michard ◽

Thierry Artzner ◽

Mathilde Deridder ◽

Camille Besch ◽

Pietro Addeo ◽

...

Keyword(s):

Intensive Care Unit ◽

Intensive Care ◽

Liver Failure ◽

Chronic Liver ◽

Chronic Liver Failure ◽

Unit Management ◽

Transplant Candidates ◽

Grade 3 ◽

Selection Of ◽

Intensive Care Unit Management

Download Full-text

Point-of-Care Echocardiography and Hemodynamic Monitoring in Cirrhosis and Acute-on-Chronic Liver Failure in the COVID-19 Era

Journal of Intensive Care Medicine ◽

10.1177/0885066620988281 ◽

2021 ◽

pp. 088506662098828

Author(s):

Madhumita Premkumar ◽

Kamal Kajal ◽

Anand V. Kulkarni ◽

Ankur Gupta ◽

Smita Divyaveer

Keyword(s):

Intensive Care ◽

Liver Failure ◽

Critically Ill ◽

Critically Ill Patients ◽

Point Of Care ◽

Kidney Injury ◽

Regional Wall Motion ◽

Chronic Liver ◽

Chronic Liver Failure ◽

Evidenced Based

Point-of-Care (POC) transthoracic echocardiography (TTE) is transforming the management of patients with cirrhosis presenting with septic shock, acute kidney injury, hepatorenal syndrome and acute-on-chronic liver failure (ACLF) by correctly assessing the hemodynamic and volume status at the bedside using combined echocardiography and POC ultrasound (POCUS). When POC TTE is performed by the hepatologist or intensivist in the intensive care unit (ICU), and interpreted remotely by a cardiologist, it can rule out cardiovascular conditions that may be contributing to undifferentiated shock, such as diastolic dysfunction, myocardial infarction, myocarditis, regional wall motion abnormalities and pulmonary embolism. The COVID-19 pandemic has led to a delay in seeking medical treatment, reduced invasive interventions and deferment in referrals leading to “collateral damage” in critically ill patients with liver disease. Thus, the use of telemedicine in the ICU (Tele-ICU) has integrated cardiology, intensive care, and hepatology practices across the spectrum of ICU, operating room, and transplant healthcare. Telecardiology tools have improved bedside diagnosis when introduced as part of COVID-19 care by remote supervision and interpretation of POCUS and echocardiographic data. In this review, we present the contemporary approach of using POC echocardiography and offer a practical guide for primary care hepatologists and gastroenterologists for cardiac assessment in critically ill patients with cirrhosis and ACLF. Evidenced based use of Tele-ICU can prevent delay in cardiac diagnosis, optimize safe use of expert resources and ensure timely care in the setting of critically ill cirrhosis, ACLF and liver transplantation in the COVID-19 era.

Download Full-text

Liver transplantation in patients admitted to intensive care with acute-on-chronic liver failure

Journal of Hepatology ◽

10.1016/s0168-8278(18)30699-8 ◽

2018 ◽

Vol 68 ◽

pp. S241-S242

Author(s):

E. Theocharidou ◽

T. Pirani ◽

M. Heneghan ◽

N. Heaton ◽

W. Bernal ◽

...

Keyword(s):

Liver Transplantation ◽

Intensive Care ◽

Liver Failure ◽

Chronic Liver ◽

Chronic Liver Failure

Download Full-text

Role of Procalcitonin in Early Detection of Infections in Acute on Chronic Liver Failure in Liver Intensive Care

Journal of Clinical and Experimental Hepatology ◽

10.1016/j.jceh.2016.06.013 ◽

2016 ◽

Vol 6 ◽

pp. S7

Author(s):

Swapnil Dhampalwar ◽

Aamritangsu Borkakoty ◽

Sunil Taneja ◽

Ajay Duseja ◽

Radha K. Dhiman ◽

...

Keyword(s):

Intensive Care ◽

Early Detection ◽

Liver Failure ◽

Chronic Liver ◽

Chronic Liver Failure

Download Full-text

Inflammasome and extrahepatic organ failure in acute-on-chronic liver failure

Journal of Public Health and Emergency ◽

10.21037/jphe.2017.03.02 ◽

2017 ◽

Vol 1 ◽

pp. 34-34

Author(s):

Carmen Sendra ◽

Javier Ampuero ◽

Manuel Romero-Gómez

Keyword(s):

Liver Failure ◽

Organ Failure ◽

Chronic Liver ◽

Chronic Liver Failure

Download Full-text

Liver failure

Oxford Textbook of Medicine ◽

10.1093/med/9780198746690.003.0321 ◽

2020 ◽

pp. 3089-3100

Author(s):

Jane Macnaughtan ◽

Rajiv Jalan

Keyword(s):

Liver Transplantation ◽

Liver Disease ◽

Hepatic Encephalopathy ◽

Liver Injury ◽

Liver Failure ◽

Acute Liver Failure ◽

Organ Failure ◽

Clinical Manifestations ◽

Chronic Liver ◽

Chronic Liver Failure

Liver failure occurs when loss of hepatic parenchymal function exceeds the capacity of hepatocytes to regenerate or repair liver injury. Acute liver failure is characterized by jaundice and prolongation of the prothrombin time in the context of recent acute liver injury, with hepatic encephalopathy occurring within 8 weeks of the first onset of liver disease. Acute-on-chronic liver failure is characterized by hepatic and/or extrahepatic organ failure in patients with cirrhosis associated with an identified or unidentified precipitating event. The commonest causes of acute liver failure are acute viral hepatitis and drugs. Acute-on-chronic liver failure is most commonly precipitated by infection, alcohol abuse, and superimposed viral infection. The main clinical manifestations are hepatic encephalopathy, coagulopathy, jaundice, renal dysfunction, and haemodynamic instability. Infection and systemic inflammation contribute to pathogenesis and critically contribute to prognosis. Specific therapy for the underlying liver disease is administered when available, but this is not possible for most causes of liver failure. Treatment is predominantly supportive, with particular emphasis on (1) correction or removal of precipitating factors; (2) if encephalopathy is present, using phosphate enemata, nonhydrolysed disaccharide laxatives, and/or rifaximin; (3) early detection and prompt treatment of complications such as hypoglycaemia, hypokalaemia, cerebral oedema, infection, and bleeding. The onset of organ failure should prompt discussion with a liver transplantation centre. The mortality of acute liver failure (without liver transplantation) is about 40%. Patients with acute liver failure who do not develop encephalopathy can be expected to recover completely. Those who recover from an episode of acute-on-chronic liver failure should be considered for liver transplantation because otherwise their subsequent mortality remains high.

Download Full-text

Acute-on-chronic liver failure: to admit to intensive care or not?

British Journal of Hospital Medicine ◽

10.12968/hmed.2020.0310 ◽

2020 ◽

Vol 81 (9) ◽

pp. 1-6

Author(s):

Asif Arshad ◽

Lylah Irshad ◽

Theodore Nabavi ◽

Tony Whitehouse

Keyword(s):

Liver Failure ◽

Organ Failure ◽

Gastrointestinal Haemorrhage ◽

Chronic Liver ◽

Organ Support ◽

Chronic Liver Failure ◽

Short Term Mortality ◽

Organ Failures ◽

Clinical Scoring ◽

Excessive Alcohol

Acute-on-chronic liver failure is used to describe an acute decline in liver function in a patient with existing liver disease combined with other organ failure. Acute-on-chronic liver failure is associated with high short-term mortality, and the greater the number and severity of organ failures, the higher the mortality. The most commonly identified precipitants of acute-on-chronic liver failure include bacterial infection, gastrointestinal haemorrhage, viral hepatitis and recent excessive alcohol intake. Since some of these aetiologies are treatable, organ failure may return to pre-decompensation levels in up to 55% of patients. As a result, a trial of critical care treatment may be appropriate for many of these patients. Clinical scoring tools may help clinicians recognise futility, allowing timely withdrawal of organ support and shifting the focus of care toward palliation.

Download Full-text

Acute-on-chronic liver failure: definition, prognosis and management

Frontline Gastroenterology ◽

10.1136/flgastro-2018-101103 ◽

2019 ◽

Vol 11 (6) ◽

pp. 458-467

Author(s):

Ahmed Amin ◽

Rajeshwar P Mookerjee

Keyword(s):

Liver Transplantation ◽

Liver Failure ◽

Organ Failure ◽

Limited Resource ◽

Chronic Liver ◽

Rapid Progression ◽

Organ Shortage ◽

Chronic Liver Failure ◽

Hepatic Decompensation ◽

Short Term Mortality

Acute-on-chronic liver failure (ACLF) is a recently described entity in chronic liver disease defined by acute hepatic decompensation, organ failure and a high risk of short-term mortality (usually less than 4 weeks). This condition is distinct from acute liver failure and stable progression of cirrhosis in numerous ways, including triggering precipitant factors, systemic inflammation, rapid progression and a potential for recovery. While a clear definition of ACLF has been forwarded from a large European Consortium study, some heterogeneity remains in how patients present and the types of organ failure, depending on whether they are described in Asian or European studies. Active alcoholism, acute alcoholic hepatitis and infections are the most frequent precipitants for ACLF. Underpinning the pathophysiology of ACLF is a state of persistent inflammation and immune dysfunction, collectively driving a systematic inflammatory response syndrome and an increased propensity to sepsis. Prevention and early treatment of organ failure are key in influencing survival. Given increasing organ shortage and more marginal grafts, liver transplantation is a limited resource and emphasises the need for new therapies to improve ACLF outcomes. Recent data indicate that liver transplantation has encouraging outcomes even in patients with advanced ACLF if patients are carefully selected during the permissive window of clinical presentation. ACLF remains a significant challenge in the field of hepatology, with considerable research and resource being channelled to improve upon the definition, prognostication, treatment and unravelling of mechanistic drivers. This Review discusses updates in ACLF definition, prognosis and management.

Download Full-text