Non-hepatic Insults Are Common Acute Precipitants in Patients with Acute on Chronic Liver Failure (ACLF)

Acute-on-chronic liver failure (ACLF) is a newly coined term to describe simultaneous coexistence of two liver conditions, one of them being chronic or long-standing and the other acute or recent. There is limited data on the entity of ACLF. This study was performed to review our experience in ACLF patients from a tertiary care centre. ACLF was defined as per the Asian Pacific Association for the Study of the Liver (APASL) criteria, except for including the non-hepatic insults as precipitating events. Based on the type of acute insult, patients were divided into type I (non hepatic injury) and type II (hepatic injury-further divided in to IIA-acute viral hepatitis (AVH) on underlying chronic liver disease (CLD), IIB-other acute hepatitic insults like drugs/toxins and IIC-same disease responsible for worsening). Patients were also analyzed for the mode of presentation, severity of liver illness, presence of acute kidney injury and other organ failure, hospital stay and final outcome. One hundred two patients with ACLF (85 males, mean age 44 +/- A 12.5 years) were included in the study; they accounted for 49% of all liver failures and 27% of all admissions during the study period. Sixty patients (59%) had known cirrhosis whereas 42 (41%) patients presented for the first time as ACLF, unaware of the underlying CLD. Sixty-two (60%) patients had type I ACLF while 40 (40%) patients had type II ACLF. Infections (47%) were the most common non-hepatic causes of acute deterioration in type I ACLF. Amongst type II, acute viral hepatitis (IIA) accounted for six patients (4 hepatitis E virus, 2 hepatitis A virus) and type II C was the most common with alcoholic hepatitis accounting for 30 (29%) patients. Acute kidney injury was present in 47 (46%) and hypotension in 36 (35%) patients. Hypoxemia with ventilatory support was required in 22 (21%) patients. Mean hospital stay of patients was 9.7 +/- A 6 days (2-27 days). Forty-seven (46%) patients either died or left hospital in a very sick state. ACLF is a common problem in our clinical practice. Non-hepatic insults like non-hepatotropic infections/sepsis are common acute precipitating events.