Early Transplantation in Acute on Chronic Liver Failure: Who and When
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MANAGEMENT OF THE CIRRHOTIC PATIENT (A CARDENAS AND P TANDON, SECTION EDITORS)
Early Transplantation in Acute on Chronic Liver Failure: Who and When Nadim Mahmud 1,2,3 & Ruben Hernaez 4 & Tiffany Wu 5 & Vinay Sundaram 6
# Springer Science+Business Media, LLC, part of Springer Nature 2020
Abstract Purpose of Review Acute on chronic liver failure (ACLF) is a unique syndrome that afflicts patients with chronic liver disease and results in high short-term mortality, > 50% at 28 days in patients with severe ACLF (grade 3, ACLF-3). Given this prognosis, there is an urgent need to understand risk factors for this condition, as well as selection criteria for patients who may benefit from liver transplantation (LT). Recent Findings Several studies have identified risk factors for developing ACLF, including higher model for end-stage liver disease score, anemia, and morbid obesity, as well ACLF mortality, such as infection, increasing organ failures, and higher white blood cell count. Prognostic tools are now available as online calculators. Regarding LT in ACLF, data suggest that even patients with ACLF-3 may do well after LT, with 1-year survival > 80% in several studies. Improvement in organ failures prior to LT, higher donor quality, and lack of mechanical ventilation further improve outcomes. Importantly, ACLF-3 patients may have higher short-term wait list mortality than patients listed status-1a, suggesting that increased LT prioritization may be warranted. Summary ACLF is a high-mortality condition that frequently responds well to LT. Ongoing efforts to understand the natural history of ACLF and predictors of improved post-LT survival will facilitate LT criteria for this condition, which may ultimately include increased LT prioritization for selected patients. Keywords End-stage liver disease . Portal hypertension . MELD score . UNOS database
Introduction Acute on chronic liver failure (ACLF) is a condition characterized by an acute insult in a patient with chronic liver disease that results in high short-term mortality. ACLF may be
precipitated by a variety of primary hepatic or extrahepatic causes, including infection, gastrointestinal bleeding, alcoholism, relapsed chronic viral hepatitis, surgery, and medications. Regardless of the precipitant, however, ACLF is uniformly characterized by short- and medium-term mortality rates of
This article is part of the Topical Collection on Management of the Cirrhotic Patient * Nadim Mahmud [email protected] Ruben Hernaez [email protected]
2
Leonard David Institute of Health Economics, University of Pennsylvania, Philadelphia, PA, USA
3
Hospital of the University of Pennsylvania, 3400 Civic Center Boulevard, 4th Floor, South Pavilion, Philadelphia, PA 19104, USA
4
Section of Gastroenterology, Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Mail stop code 111-D, 2002 Holcombe Boulevard, Houston, TX 77030, USA
5
Department of Medicine, Cedars-Sinai Medical Center, 8900 Beverly Boulevard, Suite 250, Los Angeles, CA
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