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Acute decompensation, defined as development of ascites, bacterial infection, encephalopathy, or gastrointestinal bleeding, can occur at initial presentation of advanced liver disease or episodically in patients with known cirrhosis. Progression to organ failure in patients with acute decompensation is typically termed acute-on-chronic liver failure (ACLF), which has been associated with very poor short-term survival. However, a standard definition of ACLF is lacking.
To better define ACLF, researchers prospectively evaluated risk factors and clinical outcomes of 1343 patients hospitalized in 1 of 29 liver clinics in eight European countries. Organ failure and mortality data were used to define ACLF grades and identify differences between ACLF and acute decompensation.
ACLF was diagnosed in 303 patients at study enrollment. During 28 days of follow-up, 112 patients developed ACLF, and 928 did not. The 28-day mortality rate was significantly higher both in patients who had ACLF at the time the study began (33.9%) and in those who developed ACLF during the study (29.7%) compared with patients who did not have ACLF (1.9%). Risk factors for ACLF included younger age, active alcoholism, associated bacterial infections, higher leukocyte count, and elevated C-reactive protein levels.
Moreau R et al. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013 Jun; 144:1426. (http://dx.doi.org/10.1053/j.gastro.2013.02.042)
Comment
In this large, prospective study, investigators identified acute-on-chronic liver failure in patients with cirrhosis as a distinct disease entity from cirrhosis with acute decompensation only, with the former associated with a 15-fold higher 28-day mortality rate. ACLF seems to be related to systemic inflammation or infection and active alcohol use. Differentiating between ACLF and acute decompensation alone in a clinical setting may allow clinicians to give better prognostic information to patients.