Acute-on-chronic liver failure

Abstract

Acute-on-chronic liver failure (ACLF) is an increasingly recognized distinct disease entity encompassing an acute deterioration of liver function in patients with chronic liver disease. Although there are no widely accepted diagnostic criteria for ACLF, the Asia.Pacific Association for the Study of the Liver (APASL) and the American Association for the Study of Liver Disease and the European Association for the Study of the Liver (AASLD/EASL) consensus definitions are commonly used. It is obvious that the APASL and the AASLD/EASL definitions are based on fundamentally different features. Two different definitions in two different parts of the world hamper the comparability of studies. Recently, the EASL-Chronic Liver Failure Consortium proposed new diagnostic criteria for ACLF based on analyses of patients with organ failure. There are areas of uncertainty in defining ACLF, such as heterogeneity of ACLF, ambiguity in qualifying underlying liver disease, argument for infection or sepsis as a precipitating event, etc. Although the exact pathogenesis of ACLF remains to be elucidated, alteration of host response to injury, infection, and unregulated inflammation play important roles. The predisposition, infection/inflammation, response, organ failure (PIRO) concept used for sepsis might be useful in describing the pathophysiology and clinical categories for ACLF. Treatment strategies are limited to organ support but better understanding of the pathophysiology is likely to lead to discovery of novel biomarkers and therapeutic strategies in the future.

Keywords: Acute-on-chronic liver failure; Liver cirrhosis; Liver failure.

Figure 1

A conceptual schema of acute liver failure, acute-on-chronic liver failure, and decompensated liver cirrhosis. The gray line describes the course of a patient with acute liver failure. Acute-on-chronic liver failure (ACLF) is depicted by the black line. The dotted line indicates the expected course of chronic liver disease without precipitating insults. The patient with ACLF who may often have good liver function reserve can deteriorate acutely, usually in association with a precipitating event which results in organ failure and high risk of death. This patient has a potential for reversibility and recovery to the state the patient was in, although not complete. The ACLF encompasses 'severely acute on moderate chronic liver disease' entity (A) and 'moderately acute on severe chronic liver disease' entity (B) of ACLF. The clinical concept of ACLF is different from that of life-threatening decompensation of liver cirrhosis. During the course of a patient with decompensated cirrhosis, life threatening exacerbation will at some point develop organ dysfunction where the chance of reversibility is very limited (C).

Figure 2

Patient characteristics at CANONIC study enrollment. ACLF, acute-on-chronic liver failure; GI, gastrointestinal.