title: Acute-on-chronic liver failure in India: The Indian National Association for Study of the Liver consortium experience.
abstract: OBJECTIVE
  The aim of this study was to analyze etiologies and frequency of hepatic and extrahepatic organ failures (OFs) and outcome of acute-on-chronic liver failure (ACLF) at 10 tertiary centers in India.
  
  
  METHODS
  In this retrospective study (2011-2014), patients satisfying Asian Pacific Association for the Study of the Liver definition of ACLF were included. Etiology of acute precipitating insult and chronic liver disease and outcomes were assessed. Occurrence and severity of OF were assessed by chronic liver failure-sequential organ failure assessment score.
  
  
  RESULTS
  The mean (±SD) age of 1049 consecutive ACLF patients was 44.7 ± 12.2 years; Eighty-two percent were men. Etiology of acute precipitants included alcohol 35.7%, hepatitis viruses (hepatitis A, hepatitis B, and hepatitis E) 21.4%, sepsis 16.6%, variceal bleeding 8.4%, drugs 5.7%, and cryptogenic 9.9%. Among causes of chronic liver disease, alcohol was commonest 56.7%, followed by cryptogenic and hepatitis viruses. Predictors of survival were analyzed for a subset of 381 ACLF patients; OF's liver, renal, coagulation, cerebral, respiratory, and failure were seen in 68%, 32%, 31.5%, 22.6%, 14.5%, and 15%, respectively. Fifty-seven patients had no OF, whereas 1, 2, 3, 4, and 5 OFs were recorded in 126, 86, 72, 28, and 12 patients, respectively. The mortality increased progressively with increasing number of OFs (12.3% with no OF, 83.3% with five OFs). During a median hospital stay of 8 days, 42.6% (447/1049) of patients died. On multivariate analysis by Cox proportional hazard model, elevated serum creatinine (hazard ratio [HR] 1.176), advanced hepatic encephalopathy (HR 2.698), and requirement of ventilator support (HR 2.484) were independent predictors of mortality.
  
  
  CONCLUSIONS
  Alcohol was the commonest etiology of ACLF. Within a mean hospital stay of 8 days, 42% patients died. OFs independently predicted survival.
authors.affiliation: Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
authors.affiliation: Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
authors.forename: Vivek
authors.initials: V
authors.lastname: Saraswat
authors.affiliation: S.C.B Medical College, Cuttack, India.
authors.forename: Shivaram P
authors.initials: SP
authors.lastname: Singh
authors.affiliation: Postgraduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Ajay
authors.initials: A
authors.lastname: Duseja
authors.affiliation: Seth GS Medical College and KEM Hospital, Mumbai, India.
authors.forename: Akash
authors.initials: A
authors.lastname: Shukla
authors.affiliation: Christian Medical College, Vellore, India.
authors.forename: Chundamannil E
authors.initials: CE
authors.lastname: Eapen
authors.affiliation: Army Hospital Research and Referral, New Delhi, India.
authors.forename: Dharmendra
authors.initials: D
authors.lastname: Kumar
authors.affiliation: Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India.
authors.forename: Gaurav
authors.initials: G
authors.lastname: Pandey
authors.affiliation: Global hospital, Chennai, India.
authors.forename: Jayanti
authors.initials: J
authors.lastname: Venkataraman
authors.affiliation: Madras Medical College, Chennai, India.
authors.forename: Pankaj
authors.initials: P
authors.lastname: Puri
authors.affiliation: Army Hospital Research and Referral, New Delhi, India.
authors.forename: Krishnasamy
authors.initials: K
authors.lastname: Narayanswami
authors.affiliation: Postgraduate Institute of Medical Education and Research, Chandigarh, India.
authors.forename: Radha K
authors.initials: RK
authors.lastname: Dhiman
authors.affiliation: Army Hospital Research and Referral, New Delhi, India.
authors.forename: Sandeep
authors.initials: S
authors.lastname: Thareja
authors.affiliation: SMS Medical College, Jaipur, India.
authors.forename: Sandeep
authors.initials: S
authors.lastname: Nijhawan
authors.affiliation: Seth GS Medical College and KEM Hospital, Mumbai, India.
authors.forename: Shobna
authors.initials: S
authors.lastname: Bhatia
authors.affiliation: Christian Medical College, Vellore, India.
authors.forename: Uday
authors.initials: U
authors.lastname: Zachariah
authors.affiliation: Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India.
authors.forename: Ujjwal
authors.initials: U
authors.lastname: Sonika
authors.affiliation: Medical College Hospital, Calicut, India.
authors.forename: Thomas
authors.initials: T
authors.lastname: Varghese
authors.affiliation: Department of Gastroenterology, All India Institute of Medical Sciences, New Delhi, India. subratacharya2004@yahoo.com.
authors.forename: Subrat K
authors.initials: SK
authors.lastname: Acharya
mesh_terms: D065290:Acute-On-Chronic Liver Failure / Q000453:epidemiology* / Q000209:etiology / Q000628:therapy; D000328:Adult; D000368:Aged; D004932:Esophageal and Gastric Varices / Q000150:complications / Q000453:epidemiology; D005260:Female; D006525:Hepatitis, Viral, Human / Q000150:complications / Q000453:epidemiology; D006801:Humans; D007194:India / Q000453:epidemiology; D008108:Liver Diseases, Alcoholic / Q000453:epidemiology; D008297:Male; D008875:Middle Aged; D011379:Prognosis; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016019:Survival Analysis; D055815:Young Adult
keywords: alcohol; hepatitis B; hepatitis E; organ failure; sepsis; variceal bleeding