Acute-On-On-Chronic Liver Failure
ACUTE-ON-CHRONIC LIVER FAILURE: APPLYING THE
PIRO CONCEPT
Danielle Adebayo, Vincenzo Morabito, Rajiv Jalan
Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
Disclosure: No potential conflict of interest
Citation: EMJ Hepatol. 2013;1:38-43.
ABSTRACT
Acute-on-chronic liver failure (ACLF), a clinical syndrome associated with a dismal prognosis, occurs acutely in previously stable cirrhotic patients. An important feature of this syndrome is the potential for reversibility if it is recognised early and supportive measures are instituted before multi-organ failure ensues.
In response, there have been recent efforts to better define and understand the pathophysiological …show more content…
Interventions that target inflammation may adversely impact on the ability to control the infection, and interventions that target infection may not be useful if pathophysiological process is being driven through inflammation. A classification based on the PIRO concept may allow the categorisation of patients into distinct pathophysiologic and prognostic groups and allow a multidimensional definition of ACLF.
Keywords: Acute-on-chronic liver failure, cirrhosis, liver.
INTRODUCTION
An early and proper diagnosis of acute-on-chronic liver failure (ACLF), together with the identification of indicators associated with disease severity, is critical for outcome prediction and therapy. Although this clinical entity is well recognised, it remains poorly defined due to the extreme heterogeneity in the mode of presentation. In order to clinically describe the group of patients referred to as ACLF, we adopted the definition that these patients would have an acute deterioration in liver function over a short period (up to four weeks), associated with a precipitating event in patients with well-compensated liver disease, characterised by organ failure.1,2 The high …show more content…
In addition, the presence of SIRS in patients with functional renal failure was associated with an in-hospital mortality rate of 68%.26
Further evidence that SIRS plays an important role in kidney failure associated with ACLF, is derived from studies which have shown that the use of anti-inflammatory agents, such as pentoxifylline, improves renal function or significantly decreases the risk of developing renal failure in patients with alcoholic hepatitis.27,28
Hepatorenal syndrome (HRS) is the development of functional renal failure in patients with advanced liver disease. Type 1 HRS, which occurs in an acute setting, is a rapidly progressive decline in renal function associated with a mortality rate of 80% at two weeks.29 Our current understanding is that
HRS develops as a result of the haemodynamic dysregulation associated with portal hypertension.
In this setting, splanchnic vasodilatation leads to decreased effective arterial volume, resulting in severe renal vasoconstriction and hypoperfusion.
Activation of the sympathetic nervous system through a hepatorenal reflex arc is also thought
PIRO CONCEPT
Danielle Adebayo, Vincenzo Morabito, Rajiv Jalan
Liver Failure Group, UCL Institute for Liver and Digestive Health, UCL Medical School, Royal Free Hospital, London, UK
Disclosure: No potential conflict of interest
Citation: EMJ Hepatol. 2013;1:38-43.
ABSTRACT
Acute-on-chronic liver failure (ACLF), a clinical syndrome associated with a dismal prognosis, occurs acutely in previously stable cirrhotic patients. An important feature of this syndrome is the potential for reversibility if it is recognised early and supportive measures are instituted before multi-organ failure ensues.
In response, there have been recent efforts to better define and understand the pathophysiological …show more content…
Interventions that target inflammation may adversely impact on the ability to control the infection, and interventions that target infection may not be useful if pathophysiological process is being driven through inflammation. A classification based on the PIRO concept may allow the categorisation of patients into distinct pathophysiologic and prognostic groups and allow a multidimensional definition of ACLF.
Keywords: Acute-on-chronic liver failure, cirrhosis, liver.
INTRODUCTION
An early and proper diagnosis of acute-on-chronic liver failure (ACLF), together with the identification of indicators associated with disease severity, is critical for outcome prediction and therapy. Although this clinical entity is well recognised, it remains poorly defined due to the extreme heterogeneity in the mode of presentation. In order to clinically describe the group of patients referred to as ACLF, we adopted the definition that these patients would have an acute deterioration in liver function over a short period (up to four weeks), associated with a precipitating event in patients with well-compensated liver disease, characterised by organ failure.1,2 The high …show more content…
In addition, the presence of SIRS in patients with functional renal failure was associated with an in-hospital mortality rate of 68%.26
Further evidence that SIRS plays an important role in kidney failure associated with ACLF, is derived from studies which have shown that the use of anti-inflammatory agents, such as pentoxifylline, improves renal function or significantly decreases the risk of developing renal failure in patients with alcoholic hepatitis.27,28
Hepatorenal syndrome (HRS) is the development of functional renal failure in patients with advanced liver disease. Type 1 HRS, which occurs in an acute setting, is a rapidly progressive decline in renal function associated with a mortality rate of 80% at two weeks.29 Our current understanding is that
HRS develops as a result of the haemodynamic dysregulation associated with portal hypertension.
In this setting, splanchnic vasodilatation leads to decreased effective arterial volume, resulting in severe renal vasoconstriction and hypoperfusion.
Activation of the sympathetic nervous system through a hepatorenal reflex arc is also thought