ACLF: Where are we now? The Hong Kong Association for the Study of - PowerPoint PPT Presentation

The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases ACLF: Where are we now? The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases Jasmohan S Bajaj, MD, FAASLD, AGAF, FACG, FRCP Division of Gastroenterology, Hepatology and The Hong Kong Association for the Study of Liver Diseases Nutrition, Virginia Commonwealth University and McGuire VA Medical Center, Richmond, Virginia The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases

The Hong Kong Association for the Study of Liver Diseases Outline The Hong Kong Association for the Study of Liver Diseases • Burden of ACLF The Hong Kong Association for the Study of Liver Diseases • Specific definitions and their validation The Hong Kong Association for the Study of Liver Diseases • Impact of infections • Effect of ACLF on mortality The Hong Kong Association for the Study of Liver Diseases • Effect of ACLF on transplant suitability The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases

The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases Burden of ACLF The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases

The Hong Kong Association for the Study of Liver Diseases Interim Consensus Definition 2014 The Hong Kong Association for the Study of Liver Diseases Acute on chronic liver failure is a syndrome in patients with • Chronic liver disease The Hong Kong Association for the Study of Liver Diseases • With or without previously diagnosed cirrhosis which is • Characterized by acute hepatic decompensation resulting – in liver failure (jaundice and prolongation of the INR) and The Hong Kong Association for the Study of Liver Diseases – one or more extra-hepatic organ failures • That is associated with increased risk for mortality within a period of 28 days and up to 3 months from onset The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases WGO consensus statement Jalan et al. Gastroenterology 2014; 147(1):4-10 The Hong Kong Association for the Study of Liver Diseases

The Hong Kong Association for the Study of Liver Diseases Simplified Definition of ACLF The Hong Kong Association for the Study of Liver Diseases ACLF is a condition in patients with underlying The Hong Kong Association for the Study of Liver Diseases chronic liver disease with or without cirrhosis that is associated with mortality within 3 The Hong Kong Association for the Study of Liver Diseases months in the absence of treatment of the underlying liver disease, liver support, or liver The Hong Kong Association for the Study of Liver Diseases transplantation The Hong Kong Association for the Study of Liver Diseases Bajaj JS et al :Hepatology. 2018 The Hong Kong Association for the Study of Liver Diseases

The Hong Kong Association for the Study of Liver Diseases Acute On Chronic Liver Failure: Sub Types The Hong Kong Association for the Study of Liver Diseases Jaundice The Hong Kong Association for the Study of Liver Diseases Ascites Variceal bleeding Hepatic encephalopathy Chronic Compensated The Hong Kong Association for the Study of Liver Diseases liver disease cirrhosis Decompensated cirrhosis Precipitants Type A Type B Type C Viruses ACLF ACLF ACLF The Hong Kong Association for the Study of Liver Diseases Drugs Alcohol Ischemic Surgery Sepsis Hepatic and extrahepatic The Hong Kong Association for the Study of Liver Diseases Idiopathic organ failures The Hong Kong Association for the Study of Liver Diseases

The Hong Kong Association for the Study of Liver Diseases NACSELD-ACLF score The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases Bajaj JS, et al. Hepatology 2014

The Hong Kong Association for the Study of Liver Diseases NACSELD-ACLF The Hong Kong Association for the Study of Liver Diseases NACSELD-ACLF as an independent predictor of Patient Survival in all patients. The Hong Kong Association for the Study of Liver Diseases Effect p-value Odds Ratio (95% CI) NACSELD-ACLF <0.0001 0.176 (0.121, 0.254) Age <0.0001 0.954 (0.938, 0.969) The Hong Kong Association for the Study of Liver Diseases WBC <0.0001 0.574 (0.488, 0.676) Albumin 0.0096 1.357 (1.077, 1.710) The Hong Kong Association for the Study of Liver Diseases MELD <0.0001 0.918 (0.900, 0.938) Had Infection 0.0156 0.669 (0.483, 0.927) The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases O’Leary et al NACSELD Hepatology 2018

The Hong Kong Association for the Study of Liver Diseases Increasing number of hospitalizations for ACLF and cirrhosis The Hong Kong Association for the Study of Liver Diseases 32,335 700,000 Number of hospitalizations 5% The Hong Kong Association for the Study of Liver Diseases 27,108 600,000 16,781 500,000 14,578 ACLF 7,596 1.5% The Hong Kong Association for the Study of Liver Diseases 5,407 400,000 Cirrhosis 300,000 The Hong Kong Association for the Study of Liver Diseases 200,000 100,000 The Hong Kong Association for the Study of Liver Diseases 0 2001 2003 2005 2007 2009 2011 The Hong Kong Association for the Study of Liver Diseases Allen A M et al Hepatology. 2016

The Hong Kong Association for the Study of Liver Diseases The Economic Burden of ACLF is Immense The Hong Kong Association for the Study of Liver Diseases Total cost per Mean cost per # Hospitalizations LOS Mortality The Hong Kong Association for the Study of Liver Diseases hospitalization /year year Cirrhosis 10 bill 14,894 658,884 7 7% ACLF 1.8 bill 51,841 32,335 16 50% The Hong Kong Association for the Study of Liver Diseases Pneumonia $17 billion (all 7,206 or $4913 1.1 million 5.2 4.1% costs, including outpatient) The Hong Kong Association for the Study of Liver Diseases CHF $32 bill? (all 10,775 1 million 5 5.3% costs, including outpatient) The Hong Kong Association for the Study of Liver Diseases Sepsis $24.3 billion $19,330 808,000 8.8 The Hong Kong Association for the Study of Liver Diseases CDC 2010 http://www.cdc.gov/nchs/fastats/pneumonia.htm.

The Hong Kong Association for the Study of Liver Diseases ACLF: Approach to Management The Hong Kong Association for the Study of Liver Diseases • Determine Prognosis The Hong Kong Association for the Study of Liver Diseases • Reverse precipitating event • Treat Infection The Hong Kong Association for the Study of Liver Diseases • Support organ dysfunction The Hong Kong Association for the Study of Liver Diseases • Consider liver transplantation • Future directions The Hong Kong Association for the Study of Liver Diseases The Hong Kong Association for the Study of Liver Diseases

The Hong Kong Association for the Study of Liver Diseases Comparison of the Definitions for Acute-on-Chronic Liver Failure (ACLF) Asian Pacific Association for the European Association for the North American (WGO Proposal) Study of Liver (APASL) Study of Liver-Chronic Failure Consortium for Study of (EASL-CLIF) End-stage Liver Disease The Hong Kong Association for the Study of Liver Diseases (NACSELD) Derivation Consensus and observational Prospective, observational Prospective study in Consensus study patients with Cirrhosis Patient Chronic liver disease Compensated and Decompensated Non-cirrhotic Population decompensated cirrhosis cirrhosis by implication chronic liver The Hong Kong Association for the Study of Liver Diseases Inclusion Compensated cirrhosis disease to decompensated cirrhosis Exclusion Infection, prior hepatic HCC outside Milan criteria HIV infection Not stated decompensation HIV infection Prior organ The Hong Kong Association for the Study of Liver Diseases Significant comorbidity transplantation Untreated malignancies Severity Liver failure defined as jaundice Hepatic and extrahepatic Extrahepatic organ Not Stated Score (serum bilirubin ≥5 mg/ dL) and organ failure. failure coagulopathy (INR of ≥1.5 or The Hong Kong Association for the Study of Liver Diseases prothrombin activity of ≤40%). Ascites or encephalopathy develops within 4 weeks. Comments The Hong Kong Association for the Study of Liver Diseases Diagnosis can be made early Diagnosis of ACLF may be Diagnosis of ACLF may Working enough for intervention to alter made too late to impact be made too late to definition for disease course. disease outcome. impact disease outcome. data collection Diagnosis is sensitive but not to ultimately specific for early mortality arrive at a The Hong Kong Association for the Study of Liver Diseases validated definition