Management of acute-on-chronic liver failure in cirrhosis and chronic liver disease patients: AJG guideline
USA: Acute-on-chronic liver failure (ACLF) is emerging as a major cause of mortality in patients with cirrhosis and chronic liver disease. The recent guidelines by the American College of Gastroenterology, indicate the preferred approach to the management of patients with acute-on-chronic liver failure.
According to the authors, the guideline published in the American Journal of Gastroenterology, is meant to be broadly applicable and should be viewed as the preferred, but not only, approach to clinical scenarios.
"ACLF is a relatively recently described entity that is diagnosed with a combination of hepatic and extrahepatic organ failures. The current definitions of ACLF vary worldwide, but despite these differences, patients with ACLF have a uniformly poor prognosis," Jasmohan S. Bajaj, Virginia Commonwealth University and Central Virginia Veterans Health Care System, Richmond, Virginia, USA, and colleagues wrote in their study.
"The role of ACLF prediction, precipitating factors, individual organ failures, management strategies, and impact on liver transplantation or end-of-life care is evolving. The guideline represents the synthesis of the current and emerging data on ACLF as a major entity in patients with chronic liver disease," they explained.
Given below are the key recommendations
Brain Failure
- In hospitalized patients with ACLF, we suggest the use of short-acting dexmedetomidine for sedation as compared to other available agents to shorten time to extubation.
- In patients with cirrhosis and ACLF who continue to require mechanical ventilation because of brain conditions or respiratory failure despite optimal therapy, the authors suggest against listing for LT to improve mortality.
Kidney failure
- In patients with cirrhosis and stages 2 and 3 AKI, we suggest IV albumin and vasoconstrictors as compared to albumin alone, to improve creatinine.
- In patients with cirrhosis, we suggest against the use of biomarkers to predict the development of renal failure>
- In patients with cirrhosis and elevated baseline sCr who are admitted to the hospital, the authors suggest monitoring renal function closely because elevated baseline creatinine is associated with worse renal outcomes and 30-d survival.
- In hospitalized patients with cirrhosis and HRS-AKI without high grade of ACLF or major cardiopulmonary or vascular disease, the authors suggest terlipressin or norepinephrine to improve renal function.
- In patients with cirrhosis and SBP, the authors recommend albumin in addition to antibiotics to prevent AKI and subsequent organ failures.
- In patients with cirrhosis and infections other than SBP, the authors recommend against albumin to improve renal function or mortality.
Respiratory failure:
- In ventilated patients with cirrhosis, the authors suggest against prophylactic antibiotics to reduce mortality or duration of mechanical ventilation.
Coagulation failure
- In patients with cirrhosis and ACLF, the authors suggest against INR as a means to measure coagulation risk.
- In patients with cirrhosis as compared to noncirrhotic populations, the authors suggest there is an increased risk of VTE.
- In patients with ACLF and altered coagulation parameters, the authors suggest against transfusion in the absence of bleeding or a planned procedure.
- In patients with cirrhosis who require invasive procedures, the authors recommend the use of TEG or ROTEM, compared with INR, to more accurately assess transfusion needs.
Infections
- In hospitalized decompensated cirrhotic patients, the authors recommend assessment for infection because infection is associated with the development of ACLF and increased mortality.
- In patients with cirrhosis and suspected infection, the authors suggest early treatment with antibiotics to improve survival.
Nosocomial and fungal infections
- In hospitalized patients with ACLF because of a bacterial infection who have not responded to antibiotic therapy, the authors suggest suspicion of a MDR organism or fungal infection to improve detection.
Medications and prophylaxis for infection
- In patients with cirrhosis with a history of SBP, the authors suggest use of antibiotics for secondary SBP prophylaxis to prevent recurrent SBP (unable to comment on specific antibiotic choice).
- In patients with cirrhosis in need of primary SBP prophylaxis, the authors suggest daily prophylactic antibiotics, although no one specific regimen is superior to another, to prevent SBP.
- In patients with cirrhosis, the authors suggest avoiding PPI unless there is a clear indication because PPI increases the risk of infection.
Alcohol-associated hepatitis
- In patients with severe alcohol-associated hepatitis (MDF ≥ 32; MELD score > 20) in the absence of contraindications, the authors recommend the use of prednisolone or prednisone (40 mg/d) orally to improve 28-d mortality.
- In patients with severe alcohol-associated hepatitis (MDF ≥ 32; MELD score > 20), the authors suggest against the use of pentoxifylline to improve 28-d mortality.
Management strategies
- In patients with cirrhosis who are hospitalized, the authors suggest against the routine use of parenteral nutrition, enteral nutrition, or oral supplements to improve mortality.
- In hospitalized patients with cirrhosis, the authors recommend against daily infusion of albumin to maintain albumin >3 g/dL to improve mortality, prevention of renal dysfunction, or infection.
- In patients with cirrhosis and ACLF, the authors suggest against the use of G-CSF to improve mortality.
Transplant vs futility
- In patients with cirrhosis and ACLF who continue to require mechanical ventilation because of ARDS or brain-related conditions despite optimal therapy, the authors suggest against listing for LT to improve mortality.
- In patients with end-stage liver disease admitted to the hospital, the authors suggest early goals of care discussion and if appropriate, referral to palliative care to improve resource utilization.
"These guidelines are established to support clinical practice and suggest preferable approaches to a typical patient with a particular medical problem based on the currently available published literature," the authors concluded. "When exercising clinical judgment, particularly when treatments pose significant risks, healthcare providers should incorporate this guideline in addition to patient-specific medical comorbidities, health status, and preferences to arrive at a patient-centered care approach."
Reference:
Bajaj, Jasmohan S. MD, MS, FACG1; O'Leary, Jacqueline G. MD, MPH, FACG2; Lai, Jennifer C. MD, MBA3; Wong, Florence MD, FACG4; Long, Millie D. MD, MPH, FACG (Methodologist)5; Wong, Robert J. MD, MS, FACG (Methodologist)6; Kamath, Patrick S. MD7 Acute-on-Chronic Liver Failure Clinical Guidelines, The American Journal of Gastroenterology: January 10, 2022 - Volume - Issue - 10.14309/ajg.0000000000001595 doi: 10.14309/ajg.0000000000001595
