title: Acute on chronic liver disease in children from the developing world:  recognition and prognosis.
abstract: OBJECTIVE
  A subset of children with chronic liver disease (CLD) decompensate following an acute insult; however, data for children are not readily available. The present study aims to characterize the clinical presentation, etiology, outcome, and determinants of short-term mortality in children with an acute hepatic insult superimposed over CLD.
  
  
  METHODS
  Children of acute on chronic liver disease (ACLD) were grouped as acute on chronic liver failure (ACLF) and non-ACLF. ACLF was defined as per the definition proposed by Asian Pacific Association for the Study of Liver. The acute insult, etiology of CLD, and clinical and laboratory parameters at admission along with 3-month outcome were assessed. Receiver operating curve (ROC) was plotted to measure the performance of pediatric end-stage liver disease (PELD) score in predicting the 3-month mortality.
  
  
  RESULTS
  Of the 36 children with ACLD (median age 9.5; range 3-15 years), 17 fulfilled ACLF criteria and 19 non-ACLF. CLD was diagnosed for the first time in 86% children during their presentation with a superimposed acute insult. Wilson disease and autoimmune liver disease were the most common underlying etiology. Acute insult was caused by hepatitis E virus (HEV) in 27 (75%) children and hepatitis A virus (HAV) in 10 (28%). The 3-month mortality of ACLF group was significantly higher than that of non-ACLF group (59% vs 11%, P = 0.001). PELD score of >25.5 predicted death, with a sensitivity of 100% and specificity of 83.3%.
  
  
  CONCLUSIONS
  Superinfection with hepatotropic viruses on CLD in children manifests as ACLD: ACLF and non-ACLF. Hepatitis E virus is the most common superinfection in the population studied. The mortality in ACLF is 5 times higher than that in the non-ACLF group. PELD score is useful in differentiating likely survivors and nonsurvivors.
authors.affiliation: Department of Pediatric Gastroenterology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
authors.forename: Barath
authors.initials: B
authors.lastname: Jagadisan
authors.forename: Anshu
authors.initials: A
authors.lastname: Srivastava
authors.forename: Surender Kumar
authors.initials: SK
authors.lastname: Yachha
authors.forename: Ujjal
authors.initials: U
authors.lastname: Poddar
mesh_terms: D000293:Adolescent; D001327:Autoimmune Diseases / Q000150:complications* / Q000401:mortality; D002648:Child; D002675:Child, Preschool; D058625:End Stage Liver Disease / Q000150:complications / Q000175:diagnosis / Q000401:mortality*; D005260:Female; D016751:Hepatitis E / Q000150:complications* / Q000401:mortality / Q000821:virology; D016752:Hepatitis E virus; D006527:Hepatolenticular Degeneration / Q000150:complications* / Q000401:mortality; D006801:Humans; D017114:Liver Failure, Acute / Q000150:complications / Q000401:mortality* / Q000821:virology; D008297:Male; D012372:ROC Curve; D015163:Superinfection / Q000150:complications* / Q000401:mortality / Q000821:virology