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Williams LT in ACLF

performance of the ACLF score. A very recent 2016 terminology, mechanisms and management. Nat Rev Gastroenterol
publication showed increased values for urinary Hepatol 2016;13:131-49.
neutrophil gelatinase-associated lipocalin (N-GAL) 3. Levesque E, Saliba F, Ichaï P, Samuel D. Outcome of patients
related to stage and severity of cirrhosis as another with cirrhosis requiring mechanical ventilation in ICU. J Hepatol
2014;60:570-8.
independent biomarker of ACLF prognosis. [14] N-GAL 4. Gustot T, Fernandez J, Garcia E, Morando F, Caraceni P,
is the product of up regulation of the cn2 gene in the Alessandria C, Laleman W, Trebicka J, Elkrief L, Hopf C, Solís-
liver driven by the processes of liver cell destruction. Munoz P, Saliba F, Zeuzem S, Albillos A, Benten D, Montero-
Alvarez JL, Chivas MT, Concepción M, Córdoba J, McCormick
Finally, to return to the selection and prioritisation A, Stauber R, Vogel W, de Gottardi A, Welzel TM, Domenicali
of patients for transplantation in the clinical setting. M, Risso A, Wendon J, Deulofeu C, Angeli P, Durand F, Pavesi
M, Gerbes A, Jalan R, Moreau R, Ginés P, Bernardi M, Arroyo V;
Rajiv Jalan, Royal Free Hospital, London, suggests CANONIC Study Investigators of the EASL-CLIF Consortium.
that ACLF scores of up to 30 are consistent with Clinical course of acute-on-chronic liver failure syndrome and
spontaneous recovery and patients should have serial effects on prognosis. Hepatology 2015;62:243-52.
assessments on a regular basis to determine whether 5. Jalan R, Saliba F, Pavesi M, Amoros A, Moreau R, Ginès P,
this is occurring. With a 30 to 65 score, the patient is Levesque E, Durand F, Angeli P, Caraceni P, Hopf C, Alessandria
unlikely to survive without a transplant and depending C, Rodriguez E, Solis-Muñoz P, Laleman W, Trebicka J, Zeuzem S,
on co-morbidity and other criteria should be given Gustot T, Mookerjee R, Elkrief L, Soriano G, Cordoba J, Morando F,
priority for an urgent transplant in anticipation of Gerbes A, Agarwal B, Samuel D, Bernardi M, Arroyo V; CANONIC
study investigators of the EASL-CLIF Consortium. Development
excellent results. A score above 65 raises questions of and validation of a prognostic score to predict mortality in patients
futility and withdrawal of active treatment measures. with acute-on-chronic liver failure. J Hepatol 2014;61:1038-47.
The subject is considered in some depth in a recent 6. Finkenstedt A, Nachbaur K, Zoller H, Joannidis M, Pratschke J,
paper from Putignano and Gustot. [15] Graziadei IW, Vogel W. Acute-on-chronic liver failure: excellent
outcomes after liver transplantation but high mortality on the wait
In summary, 3 points relating to transplantation in list. Liver Transpl 2013;19:879-86.
ACLF: firstly, improvement or worsening in ACLF 7. Bañares R, Nevens F, Larsen FS, Jalan R, Albillos A, Dollinger M,
Saliba F, Sauerbruch T, Klammt S, Ockenga J, Pares A, Wendon
grade occur rapidly and likely survival is best J, Brünnler T, Kramer L, Mathurin P, de la Mata M, Gasbarrini A,
predicted at 3-7 days; secondly, transplantation gives Müllhaupt B, Wilmer A, Laleman W, Eefsen M, Sen S, Zipprich A,
good results in those with deteriorating ACLF grades Tenorio T, Pavesi M, Schmidt HH, Mitzner S, Williams R, Arroyo
2 to 3 but timing, priority and selection criteria need V; RELIEF study group. Extracorporeal albumin dialysis with the
to be defined; thirdly, liver support devices, plasma molecular adsorbent recirculating system in acute-on-chronic liver
exchange, anti-inflammatory agents and stimulation of failure: the RELIEF trial. Hepatology 2013;57:1153-62.
regeneration require further evaluation. 8. Mao W, Ye B, Lin S, Fu Y, Chen Y, Chen Y. Prediction value of
model for end-stage liver disease scoring system on prognosis in
the acute on chronic liver failure patients with plasma exchange
Authors’ contributions treatment. ASAIO J 2010;56:475-8.
R. Williams contributed solely. 9. Ling Q, Xu X, Wei Q, Liu X, Guo H, Zhuang L, Chen J, Xia Q,
Xie H, Wu J, Zheng S, Li L. Downgrading MELD improves the
Financial support and sponsorship outcomes after liver transplantation in patients with acute-on-
chronic hepatitis B liver failure. PLoS One 2012;7:e30322.
None. 10. Wan YM, Yang LH, Yang JH, Xu Y, Yang J, Song GB. The effect
of plasma exchange on entecavir-treated chronic hepatitis B patients
Conflicts of interest with hepatic de-compensation and acute-on-chronic liver failure.
Hepatol Int 2015;10:462-9.
There are no conflicts of interest. 11. Larsen FS, Schmidt LE, Bernsmeier C, Rasmussen A, Isoniemi H,
Patel VC, Triantafyllou E, Bernal W, Auzinger G, Shawcross D,
Patient consent Eefsen M, Bjerring PN, Clemmesen JO, Hockerstedt K, Frederiksen
Not applicable. HJ, Hansen BA, Antoniades CG, Wendon J. High-volume plasma
exchange in patients with acute liver failure: an open randomised
controlled trial. J Hepatol 2016;64:69-78.
Ethics approval 12. Garg V, Garg H, Khan A, Trehanpati N, Kumar A, Sharma BC,
Not applicable. Sakhuja P, Sarin SK. Granulocyte colony-stimulating factor
mobilizes CD34(+) cells and improves survival of patients with
acute-on-chronic liver failure. Gastroenterology 2012;142:505-12.
REFERENCES e1.
13. Duan XZ, Liu FF, Tong JJ, Yang HZ, Chen J, Liu XY, Mao YL,
1. Jalan R, Moreau R, Kamath PS, Arroyo V. Acute-on-chronic liver Xin SJ, Hu JH. Granulocyte-colony stimulating factor therapy
failure: a distinct clinical condition. Semin Liver Dis 2016;36:107-8. improves survival in patients with hepatitis B virus-associated acute-
2. Sarin SK, Choudhury A. Acute-on-chronic liver failure: on-chronic liver failure. World J Gastroenterol 2013;19:1104-10.
Hepatoma Research ¦ Volume 3 ¦ May 17, 2017 93