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Acute on Chronic Liver Failure: An Update

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Peri-operative Anesthetic Management in Liver Transplantation

Abstract

Acute on chronic liver failure is a serious ailment which is associated with rapid development of liver failure which progresses to multiorgan failure in the absence of liver transplantation. The incidence of acute on chronic liver failure (ACLF) has been steadily increasing secondary to excessive alcohol use, usage of over-the-counter hepatotoxic drugs, complementary and alternative medicines, and the rising epidemic of non-alcoholic fatty liver disease. ACLF is defined differently by the European association for the study of Liver disease and the Asian Pacific Association for the Study of Liver (APASL). Conceptually liver failure is a driver of extrahepatic organ failures according to the APASL definition while EASL defines ACLF based on the presence of two or more organ failures which should include the kidneys and the brain. Sepsis is a consequence of liver failure according to the APASL while it can predispose to development of ACLF according to the EASL definition. However, both definitions converge on the concept of high 28-day mortality and a potential for reversibility and presence and severity of systemic inflammatory response syndrome as a key factor causing secondary organ failures. Therapeutic strategies using anti-inflammatory drugs, artificial liver support are an unmet need in patients with ACLF. At the same time, strategies for potentiating liver regeneration and modulation of gut dysbiosis are an area of active research in these patients. Prognostic models to identify patients who need an emergency liver transplant and those who would achieve reversibility are required which could lead to appropriate stratification of these patients.

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Abbreviations

ACLF:

Acute on chronic liver failure

AKI:

Acute kidney injury

AKIN:

Acute kidney injury network

ALF:

Acute liver failure

AOPP:

Advanced oxidative protein products

APASL:

Asian Pacific Association for the study of liver

ATN:

Acute tubular necrosis

ATP:

Adenosine triphosphate

CAM:

Complementary and alternative medicines

CK18:

Caspase-cleaved keratin18

CLD:

Chronic liver disease

CLIF:

Chronic liver failure

CRP:

C-reactive protein

CRRT:

Continuous renal replacement therapy

CysC:

Cystatin C

DAMP:

Damage associated molecular patterns

DDLT:

Deceased donor liver transplant

EASL:

European Association for the study of liver

eGFR:

Estimated glomerular filtration rate

FPSA:

Fractionated plasma separation and adsorption

G-CSF:

Granulocyte colony stimulating factor

HBV:

Hepatitis-B virus

HCC:

Hepatocellular carcinoma

HE:

Hepatic encephalopathy

HIV:

Human immunodeficiency virus

HMGB1:

High mobility group protein B1

HRS:

Hepatorenal syndrome

iACLF:

Infection related

ICA:

International club of ascites

ICU:

Intensive care unit

IL:

Interleukin

IL-1RA:

IL-1 receptor antagonist

INR:

International normalized ratio

K18:

Keratin 18

KCH:

King’s College Hospital criteria

KIM-1:

Kidney-Injury molecule

LDLT:

Living donor liver transplant

L-FABP:

Liver fatty acid binding protein

LPS:

Lipopolysaccharide

LT:

Liver transplant

MAP:

Mean arterial pressure

MARS:

Molecular adsorbents recirculatory system

MELD:

Model for end-stage liver disease

MERTK:

Mer tyrosine-protein kinase

MHE:

Minimal hepatic encephalopathy

NAC:

N-acetyl cysteine

NACSELD:

 North American consortium for the study of end-stage liver disease

NASH:

Non alcoholic steatohepatitis

NGAL:

Neutrophil gelatinase-associated lipocalin

OLT:

Orthotopic liver transplantation

PAMPs:

Pathogen-associated molecular patterns

PICD:

Paracentesis induced circulatory dysfunction

PIRO:

Predisposition, injury, response, organ failure

RAAS:

Rennin–Angiotensin aldosterone

ROTEM:

Rotational thromboelastometry

SBP:

Spontaneous bacterial peritonitis

SIRS:

Systemic inflammatory response syndrome

SOFA:

Sequential organ failure assessment

SPAD:

Single-pass albumin dialysis

TEG:

Thromboelastography

TNF-α:

Tumor necrosis factor alpha

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Authors and Affiliations

  1. Department of Internal Medicine, University of Connecticut, Farmington, CT, USA

    Manasvi Gupta

  2. Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India

    Rakhi Maiwall

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  1. Manasvi Gupta
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  2. Rakhi Maiwall
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Editors and Affiliations

  1. Liver Transplant, GI Anesthesia & Intensive Care, Medanta The Medicity, Gurgaon, India

    Vijay Vohra

  2. Liver Transplant, GI Anesthesia & Critical Care, Medanta The Medicity, Gurgaon, Haryana, India

    Nikunj Gupta

  3. Liver Transplant & General Anaesthesia, Narayana Superspeciality Hospital, Gurgaon, India

    Annu Sarin Jolly

  4. Liver Transplant, GI Anesthesia & Critical Care, Formerly at Medanta The Medicity, Gurgaon, India

    Seema Bhalotra

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Gupta, M., Maiwall, R. (2023). Acute on Chronic Liver Failure: An Update. In: Vohra, V., Gupta, N., Jolly, A.S., Bhalotra, S. (eds) Peri-operative Anesthetic Management in Liver Transplantation. Springer, Singapore. https://doi.org/10.1007/978-981-19-6045-1_43

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