Navigating the Labyrinth: Intensive Care Challenges for Patients with Acute-on-Chronic Liver Failure
Abstract
:1. Introduction
2. Methods
2.1. Definition of ACLF
2.2. System Failure and Mortality
2.3. CLIF Consortium ACLF Score
2.4. Cirrhosis-Associated Immune Dysfunction
2.5. Admission of Patients with ACLF to the ICU
2.6. The Essentials of Cardiovascular Care
2.7. The Use of β-Blockers in Patients with Sepsis or ACLF Is Still a Topic of Discussion
2.8. Acute Kidney Injury: Intervention and Care
2.9. Infections in Patients with ACLF
2.10. Biomarkers
2.11. How the Brain Responds: Cerebral Reactions
2.12. The Dynamics of Coagulation in Patients with ACLF
2.13. Beyond Conventional Treatments: The Impact of Liver Assist Devices
2.13.1. Bioartifical Liver Assist Device
2.13.2. Non-Biological Devices
2.14. Futility Criteria for Liver Transplantation
3. Conclusions
Author Contributions
Funding
Institutional Review Board Statement
Informed Consent Statement
Data Availability Statement
Conflicts of Interest
References
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Criteria | EASL | APASL | NACSELD |
---|---|---|---|
Definition | Acute worsening of preexisting liver disease, often triggered by an event, leads to increased 4-week mortality due to organ failure. | Acute deterioration of the liver leading to jaundice and hemostasis disorder within 4 weeks causes ascites/encephalopathy in known or unknown chronic liver disease with high 4-week mortality. | Chronic liver disease, with or without cirrhosis, causes mortality within 3 months if left untreated. |
Liver Failure Criteria | Bilirubin > 12 mg/dL | Bilirubin > 5 mg/dL, INR > 1.5, or prothrombin activity < 40% | Not specified |
Extrahepatic Failure | Renal: Creatinine ≥ 2.0 mg/dL or dialysis; Brain: West Haven HE grades 3–4; Circulation: any Vasopressor use; Respiration: PaO2/FiO2 ≤ 200 mmHg, SpO2/FiO2 ≤ 214, or mechanical ventilation | Renal: Dialysis; Brain: West Haven HE grades 3–4; Circulation: Shock (MAP < 60 mm Hg); Respiration: Mechanical ventilation | Renal: Dialysis; Brain: West Haven HE grades 3–4; Circulation: Shock presence (MAP < 60 mmHg); Respiration: Mechanical ventilation is required |
Type of Acute Insult | Primarily, alcohol and bacterial infections | Primary viral infections | Primarily bacterial infections, not specified |
Timeframe of Acute Insult | Not specified | Within 4 weeks | Within 3 months |
Disease Severity Assessment | CLIF-SOFA score | No specific score | No specific score |
ACLF Grade | Clinical Presentation |
---|---|
No ACLF | No organ failure or single non-kidney organ failure; creatinine <1.5 mg/dL; no hepatic encephalopathy (HE) |
ACLF Grade 1 | Single renal failure OR single non-kidney organ failure, creatinine 1.5–1.9 mg/dL, and/or HE grades 1–2 |
ACLF Grade 2 | Two organ failures |
ACLF Grade 3 | Three or more organ failures |
ACLF Classification | Mortality Day 28 | Mortality Day 90 | Mortality Day 180 |
---|---|---|---|
No ACLF | 10% | 24% | 38% |
ACLF Grade 1 | 21% | 42% | 47% |
ACLF Grade 2 | 57% | 74% | 79% |
ACLF Grade 3 | 87% | 95% | 96% |
Organ/System | Variable | Score = 1 | Score = 2 | Score = 3 |
---|---|---|---|---|
Liver | Bilirubin (mg/dL) | Less than 6 | 6 to less than 12 | 12 or more |
Coagulation | INR | Less than 2 | 2 to less than 2.5 | 2.5 or more |
Kidney | Creatinine (mg/dL) | Less than 2 | 2 to less than 3.5 | 3.5 or more, or renal replacement therapy |
Brain | Encephalopathy grade (West Haven Criteria) | Grade 0 | Grade 1–2 | Grade 3–4 |
Circulation | MAP (mm Hg) | 70 or more | Less than 70 | Use of Vasopressors |
Respiratory | PaO2/FiO2 ratio | More than 300 | More than 200 and 300 or less | 200 or less |
SpO2/FiO2 ratio | More than 357 | More than 214 and 357 or less | 214 or less |
ELAIN [55] Zarbock et al. | AKIKI [53] Gaudry et.al | IDEAL-ICU [52] Barbar et. al | START-AKI [56] Investigators Group | |
---|---|---|---|---|
Patients (n) | 231 | 620 | 477 | 2927 |
Setting | 95% (Cardiac surgery) | 80% Sepsis | 100% septic Shock | 67% medical patients |
Criteria early | AKI II° and NGAL ≥ 150 ng/mL | AKI III | Stage F of RIFLE | AKI II |
Criteria late | AKI III | Urgent indicaton for dialys3s | 48 h Remaining at Stage F | Urgent indication |
Primary endpoint | 90 day mortality | 60 day mortality | 90-day Mortality | 90-day mortality |
Mortality early group | 39% (p = 0.03) | 49% | 58% | 44% |
Mortality Late group | 55% | 50% | 54% | 44% |
Mortality Dialyzed Late Group | NA | 62% | 68% | NA |
Rate of non-dialysis in late group | 9.2% | 49% | 38% | 38% |
Dependence on dialysis on 90-days after randomization | 13 vs. 15 | 2 vs. 5 | 2 vs. 3 | 10.4. vs. 6; RR 1.74 95% CI [1.24–2.43] |
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© 2024 by the authors. Licensee MDPI, Basel, Switzerland. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution (CC BY) license (https://creativecommons.org/licenses/by/4.0/).
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Saner, F.H.; Raptis, D.A.; Alghamdi, S.A.; Malagó, M.M.; Broering, D.C.; Bezinover, D. Navigating the Labyrinth: Intensive Care Challenges for Patients with Acute-on-Chronic Liver Failure. J. Clin. Med. 2024, 13, 506. https://doi.org/10.3390/jcm13020506
Saner FH, Raptis DA, Alghamdi SA, Malagó MM, Broering DC, Bezinover D. Navigating the Labyrinth: Intensive Care Challenges for Patients with Acute-on-Chronic Liver Failure. Journal of Clinical Medicine. 2024; 13(2):506. https://doi.org/10.3390/jcm13020506
Chicago/Turabian StyleSaner, Fuat H., Dimitri A. Raptis, Saad A. Alghamdi, Massimo M. Malagó, Dieter C. Broering, and Dmitri Bezinover. 2024. "Navigating the Labyrinth: Intensive Care Challenges for Patients with Acute-on-Chronic Liver Failure" Journal of Clinical Medicine 13, no. 2: 506. https://doi.org/10.3390/jcm13020506