title: Acute-on-chronic liver failure: a prospective study to determine the clinical profile, outcome, and factors predicting mortality.
abstract: BACKGROUND
  Acute-on-chronic liver failure (ACLF), defined differently by different associations, lacks consensus on clinical profile, precipitating events and factors predicting mortality. This prospective multicentric study was conducted to determine the relevance of European Association for Study of Liver (EASL) and Asia Pacific Association for Study of Liver (APASL) definitions and to determine prognostic factors predicting the survival.
  
  
  METHODS
  Consecutive patients over a 3-month period with any form of acute deterioration were evaluated for presence of ACLF, as defined by APASL or EASL-Chronic Liver Failure (CLIF) criteria. Those enrolled underwent complete evaluation for identifying the acute insults, underlying chronic etiologies, presence of organ failures, and short-term survival.
  
  
  RESULTS
  Sixty-two patients (median age 53 years, 51 males) who presented with either raised bilirubin (n = 52), international normalized ratio (INR) >1.5 (n = 46), new onset ascites (n = 53), or hepatic encephalopathy (n = 39) were included in study. Forty-four patients (36 males, 25 alcoholics) satisfied APASL definition of ACLF, with a mortality rate of 43.1 %. Hepatic encephalopathy (p-value 0.022) was significantly associated with mortality. By CLIF-Sequential Organ Failure Assessment (SOFA) score criteria for organ failure, 50 patients (80.6 %) had at least 1 organ failure whereas 15 had ≥3 organ failures (mortality rate >75 %). Twenty-nine patients classified as ACLF (1, 2, or 3) as per EASL-CLIF criteria. Bacterial infection, >1 precipitating event, additional organ failure, total leukocyte count, INR, and serum creatinine were significantly higher in patients with ACLF across all grades. Mortality rates were 6.6 and >60 % in patients with ACLF only by APASL criteria vs. by both criteria, respectively.
  
  
  CONCLUSIONS
  ACLF, as defined by APASL in terms of liver failure, identified some patients with better survival rates as compared to EASL-CLIF definition which identifies presence of additional organ failures and high mortality.
authors.affiliation: Bombay Hospital and Medical Research Center, 12, Marine Lines, Mumbai, 400 020, India.
authors.forename: Deepak
authors.initials: D
authors.lastname: Amarapurkar
authors.forename: Mrudul V
authors.initials: MV
authors.lastname: Dharod
authors.forename: Madhuri
authors.initials: M
authors.lastname: Chandnani
authors.forename: Rajiv
authors.initials: R
authors.lastname: Baijal
authors.forename: Praveen
authors.initials: P
authors.lastname: Kumar
authors.forename: Mayank
authors.initials: M
authors.lastname: Jain
authors.forename: Nikhil
authors.initials: N
authors.lastname: Patel
authors.forename: Praful
authors.initials: P
authors.lastname: Kamani
authors.forename: Sanjeev
authors.initials: S
authors.lastname: Issar
authors.forename: Nimish
authors.initials: N
authors.lastname: Shah
authors.forename: Sandeep
authors.initials: S
authors.lastname: Kulkarni
authors.forename: Sonali
authors.initials: S
authors.lastname: Gautam
authors.forename: Apurva
authors.initials: A
authors.lastname: Shah
authors.forename: Soham
authors.initials: S
authors.lastname: Doshi
mesh_terms: D065290:Acute-On-Chronic Liver Failure / Q000401:mortality*; D000293:Adolescent; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001663:Bilirubin / Q000097:blood; D005260:Female; D006501:Hepatic Encephalopathy; D006801:Humans; D007194:India; D019934:International Normalized Ratio; D008297:Male; D008875:Middle Aged; D063305:Organ Dysfunction Scores; D011379:Prognosis; D011446:Prospective Studies; D015996:Survival Rate; D055815:Young Adult
chemical_list: D001663:Bilirubin