Acute on Chronic Liver Failure: Pan India Spectrum

Background: Acute on chronic liver failure (ACLF) is a recently described clinical syndrome with high mortality and its aetiology, natural course and pathogenesis may have regional differences. The definitions emanating from east and west are distinct and different. Information on ACLF from India is scarce. AIM: To collate and analyse the etiologies, clinical presentations, and frequency of hepatic and extra-hepatic organ failure, as well as mortality, in consecutive patients with ACLF at 9 tertiary centres in India. Methods: In this retrospective study, consecutive patients satisfying the modified APASL definition of ACLF from 2011 to 2014 were included. The aetiology of the acute event, underlying chronic liver disease and natural course, as well as outcomes, were evaluated. Results: Nine hundred seventy three consecutive ACLF patients were included; mean (±sd) age was 43.9 ± 12.3 years (range 18–82 years, median 45 years) and 796 (82%) were men. The clinical presentation included jaundice in all, ascites in 92% (759/824) and hepatic encephalopathy 56% (465/832). The etiology of acute participants (n = 943) included alcohol in 38% (362), hepatitis viruses (hepatitis A, hepatitis B and hepatitis E) 22% (203), sepsis 16.0% (151), variceal bleeding 8.7% (85), drugs 5.5% (53) and various miscellaneous causes in 10.3% (89) of patients. Among the causes of chronic liver disease, alcohol was the most common 57.1% (539), followed by hepatitis viruses (hepatitis B and hepatitis C) 15.9% (150), cryptogenic 9.5% (90) and others 17.3% (164) of cases. Infection was documented in 29% (125/433) of patients during hospitalisation. The chronic liver failure-sequential organ failure assessment (CLIF-SOFA) included liver failure in 58.1% (538/925), renal 62% (572/929), cerebral 11% (95/832), coagulation 32.7% (265/809), respiratory 14.1% (66/466) and circulatory failure in 14.2% (48/338). A total of 45% (430/949) of patients died, mean duration of hospital stay was 10.6 ± 9.4 days. Conclusions: Alcohol was the commonest aetiology of underlying chronic liver diseases and continuous consumption was also the commonest cause of ACLF in the Indian subcontinent. Liver failure and renal failure were the most frequent organ failures. Within a mean hospital stay of around 10 days, 45% died.