title: Hepatic and systemic hemodynamic derangements predict early mortality and recovery in patients with acute-on-chronic liver failure.
abstract: OBJECTIVE
  Acute-on-chronic liver failure (ACLF) is a clinical entity where there is a potential for reversibility of hepatic dysfunction once the acute hepatic insult resolves. The portal and systemic hemodynamics in ACLF patients to study its relevance in determining the clinical outcomes was studied.
  
  
  METHODS
  Clinical, laboratory, portal, and systemic hemodynamic assessments were done at admission and after 3 months. Standard medical care was given to all the patients.
  
  
  RESULTS
  Fifty-seven patients with ACLF were enrolled, and they underwent baseline hepatic venous pressure gradient (HVPG) measurement. Twenty-six (46%) patients died during the 3-month follow-up. Presence of high HVPG and hepatic encephalopathy were found to be independent baseline predictors of mortality. Of the 31 surviving patients, 24 consented for a repeat HVPG. The baseline HVPG reduced from 16 (range 12-30) to 13 (range 6-21) mmHg; (P < 0.05). The reduction in HVPG correlated with clinical and biochemical recovery, and reduction in Child-Turcotte-Pugh score score (P < 0.05), while the aortic mean arterial pressure, cardiac index and systemic vascular resistance index improved significantly (< 0.05). Six (25%) patients developed upper gastrointestinal bleed; the median HVPG between bleeders and non-bleeders was not different possibly because of early onset of bleed (median 20 [15-45 days]).
  
  
  CONCLUSIONS
  Baseline HVPG is an independent predictor of mortality in ACLF patients. The portal and systemic circulatory anomalies regress substantially by 90 days and correlate with clinical recovery. However, in the initial phase, the raised portal pressure predisposes these patients to high risk of variceal bleeding.
authors.affiliation: Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), New Delhi, India; Department of Gastroenterology, GB Pant Hospital, New Delhi, India.
authors.forename: Hitendra
authors.initials: H
authors.lastname: Garg
authors.forename: Ashish
authors.initials: A
authors.lastname: Kumar
authors.forename: Vishal
authors.initials: V
authors.lastname: Garg
authors.forename: Manoj
authors.initials: M
authors.lastname: Kumar
authors.forename: Ramesh
authors.initials: R
authors.lastname: Kumar
authors.forename: Barjesh Chander
authors.initials: BC
authors.lastname: Sharma
authors.forename: Shiv Kumar
authors.initials: SK
authors.lastname: Sarin
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D058625:End Stage Liver Disease / Q000401:mortality / Q000503:physiopathology* / Q000628:therapy; D005260:Female; D005500:Follow-Up Studies; D005544:Forecasting; D006439:Hemodynamics; D006801:Humans; D008099:Liver / Q000098:blood supply*; D017114:Liver Failure, Acute / Q000401:mortality / Q000503:physiopathology* / Q000628:therapy; D008297:Male; D008875:Middle Aged; D017082:Portal Pressure; D011168:Portal System / Q000503:physiopathology*; D011379:Prognosis; D011446:Prospective Studies; D011652:Pulmonary Circulation; D013997:Time Factors; D014655:Vascular Resistance; D055815:Young Adult
keywords: ACLF; acute-on-chronic liver failure; hepatic venous pressure gradients; pulmonary hemodynamics; systemic hemodynamics