Download PDF
Semin Liver Dis 2016; 36(02): 117-122
DOI: 10.1055/s-0036-1583204
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Acute-on-Chronic Liver Failure: The Role of Precipitating Illness

Elsa Solà
1   Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
,
Javier Fernandez
1   Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
,
Pere Ginès
1   Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEReHD), Barcelona, Spain
› Author Affiliations
Further Information

Publication History

Publication Date:
12 May 2016 (online)

    Permissions and Reprints

Abstract

Acute-on-chronic liver failure (ACLF) is a complex syndrome that develops in patients with cirrhosis at any stage during the natural history of the disease. In most cases, the development of ACLF is associated with an identifiable precipitating factor. Overall, the most common precipitating events are bacterial infections. Although data suggest that any type of infection may trigger ACLF, spontaneous bacterial peritonitis, secondary peritonitis, and pneumonia appear to be the most common types of infection leading to ACLF. Nevertheless, frequency and characteristics of precipitating factors differ among geographical areas. Although in the West the most common precipitating factors are bacterial infections followed by active alcoholism, in the East the most common triggering events are exacerbation of hepatitis B virus followed by bacterial infections. Although precipitating events may be crucial in the development of ACLF, mortality appears to be independent of the type of precipitating factor. Finally, it should be noted that in up to 20 to 40% of patients with ACLF no precipitating factor can be identified. It is suggested that in these patients, bacterial products derived from bacterial translocation or damage-associated molecular patterns resulting from injured liver tissue cells may act as triggering factors.

Keywords

acute-on-chronic liver failure - precipitating factors - bacterial infections - cirrhosis - hepatitis B virus
 

  • References

  • 1 Moreau R, Jalan R, Ginès P , et al; CANONIC Study Investigators of the EASL–CLIF Consortium. Acute-on-chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013; 144 (7) 1426-1437 , 1437.e1–1437.e9
    CrossrefPubMedGoogle Scholar
  • 2 Arroyo V, Moreau R, Jalan R, Ginès P ; EASL-CLIF Consortium CANONIC Study. Acute-on-chronic liver failure: a new syndrome that will re-classify cirrhosis. J Hepatol 2015; 62 (1, Suppl): S131-S143
    CrossrefPubMedGoogle Scholar
  • 3 Bernal W, Jalan R, Quaglia A, Simpson K, Wendon J, Burroughs A. Acute-on-chronic liver failure. Lancet 2015; 386 (10003) 1576-1587
    CrossrefPubMedGoogle Scholar
  • 4 Jalan R, Yurdaydin C, Bajaj JS , et al; World Gastroenterology Organization Working Party. Toward an improved definition of acute-on-chronic liver failure. Gastroenterology 2014; 147 (1) 4-10
    CrossrefPubMedGoogle Scholar
  • 5 Shi Y, Yang Y, Hu Y , et al. Acute-on-chronic liver failure precipitated by hepatic injury is distinct from that precipitated by extrahepatic insults. Hepatology 2015; 62 (1) 232-242
    CrossrefPubMedGoogle Scholar
  • 6 Bajaj JS. Defining acute-on-chronic liver failure: will East and West ever meet?. Gastroenterology 2013; 144 (7) 1337-1339
    CrossrefPubMedGoogle Scholar
  • 7 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 (1) 269-282
    CrossrefPubMedGoogle Scholar
  • 8 Li H, Pavesi M, Zeng B, Chen LY, Li ST, Qui DK , et al. “Eastern” type of acute-on-chronic liver failure (ACLF) is similar in pathophysiologic, diagnostic and prognostic criteria to the “Western” type: a comparison of Chinese hospitalized patients with hepatitis B with CANONIC data. Hepatology 2014; 60 (Suppl S1): 480A-481A
    PubMedGoogle Scholar
  • 9 Kubes P, Mehal WZ. Sterile inflammation in the liver. Gastroenterology 2012; 143 (5) 1158-1172
    CrossrefPubMedGoogle Scholar
  • 10 Adebayo D, Morabito V, Andreola F , et al. Mechanism of cell death in acute-on-chronic liver failure: a clinico-pathologic-biomarker study. Liver Int 2015; 35 (12) 2564-2574
    CrossrefPubMedGoogle Scholar
  • 11 Li H, Xia Q, Zeng B , et al. Submassive hepatic necrosis distinguishes HBV-associated acute on chronic liver failure from cirrhotic patients with acute decompensation. J Hepatol 2015; 63 (1) 50-59
    CrossrefPubMedGoogle Scholar
  • 12 Hamid SS, Atiq M, Shehzad F , et al. Hepatitis E virus superinfection in patients with chronic liver disease. Hepatology 2002; 36 (2) 474-478
    CrossrefPubMedGoogle Scholar
  • 13 Kumar Acharya S, Kumar Sharma P, Singh R , et al. Hepatitis E virus (HEV) infection in patients with cirrhosis is associated with rapid decompensation and death. J Hepatol 2007; 46 (3) 387-394
    CrossrefPubMedGoogle Scholar
  • 14 Ramachandran J, Eapen CE, Kang G , et al. Hepatitis E superinfection produces severe decompensation in patients with chronic liver disease. J Gastroenterol Hepatol 2004; 19 (2) 134-138
    CrossrefPubMedGoogle Scholar
  • 15 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 (2) 59-62
    PubMedGoogle Scholar
  • 16 Gustot T, Durand F, Lebrec D, Vincent JL, Moreau R. Severe sepsis in cirrhosis. Hepatology 2009; 50 (6) 2022-2033
    CrossrefPubMedGoogle Scholar
  • 17 Fernández J, Gustot T. Management of bacterial infections in cirrhosis. J Hepatol 2012; 56 (Suppl. 01) S1-S12
    PubMedGoogle Scholar
  • 18 Arvaniti V, D'Amico G, Fede G , et al. Infections in patients with cirrhosis increase mortality four-fold and should be used in determining prognosis. Gastroenterology 2010; 139 (4) 1246-1256 , 1256.e1–1256.e5
    CrossrefPubMedGoogle Scholar
  • 19 Jalan R, Fernández J, Wiest R , et al. Bacterial infections in cirrhosis: a position statement based on the EASL Special Conference 2013. J Hepatol 2014; 60 (6) 1310-1324
    CrossrefPubMedGoogle Scholar
  • 20 Follo A, Llovet JM, Navasa M , et al. Renal impairment after spontaneous bacterial peritonitis in cirrhosis: incidence, clinical course, predictive factors and prognosis. Hepatology 1994; 20 (6) 1495-1501
    CrossrefPubMedGoogle Scholar
  • 21 Navasa M, Follo A, Filella X , et al. Tumor necrosis factor and interleukin-6 in spontaneous bacterial peritonitis in cirrhosis: relationship with the development of renal impairment and mortality. Hepatology 1998; 27 (5) 1227-1232
    CrossrefPubMedGoogle Scholar
  • 22 Sort P, Navasa M, Arroyo V , et al. Effect of intravenous albumin on renal impairment and mortality in patients with cirrhosis and spontaneous bacterial peritonitis. N Engl J Med 1999; 341 (6) 403-409
    CrossrefPubMedGoogle Scholar
  • 23 Terra C, Guevara M, Torre A , et al. Renal failure in patients with cirrhosis and sepsis unrelated to spontaneous bacterial peritonitis: value of MELD score. Gastroenterology 2005; 129 (6) 1944-1953
    CrossrefPubMedGoogle Scholar
  • 24 Fernández J, Acevedo J, Castro M , et al. Prevalence and risk factors of infections by multiresistant bacteria in cirrhosis: a prospective study. Hepatology 2012; 55 (5) 1551-1561
    CrossrefPubMedGoogle Scholar
  • 25 Bernardi M, Moreau R, Angeli P, Schnabl B, Arroyo V. Mechanisms of decompensation and organ failure in cirrhosis: from peripheral arterial vasodilation to systemic inflammation hypothesis. J Hepatol 2015; 63 (5) 1272-1284
    CrossrefPubMedGoogle Scholar
  • 26 Sriskandan S, Altmann DM. The immunology of sepsis. J Pathol 2008; 214 (2) 211-223
    CrossrefPubMedGoogle Scholar
  • 27 Devière J, Content J, Denys C , et al. Excessive in vitro bacterial lipopolysaccharide-induced production of monokines in cirrhosis. Hepatology 1990; 11 (4) 628-634
    CrossrefPubMedGoogle Scholar
  • 28 Medzhitov R, Schneider DS, Soares MP. Disease tolerance as a defense strategy. Science 2012; 335 (6071) 936-941
    CrossrefPubMedGoogle Scholar
  • 29 Wiest R, Lawson M, Geuking M. Pathological bacterial translocation in liver cirrhosis. J Hepatol 2014; 60 (1) 197-209
    CrossrefPubMedGoogle Scholar
  • 30 Albillos A, Lario M, Álvarez-Mon M. Cirrhosis-associated immune dysfunction: distinctive features and clinical relevance. J Hepatol 2014; 61 (6) 1385-1396
    CrossrefPubMedGoogle Scholar