aclf

1. MORTALITY MEETING BHDC
07 JUL 2017
PRESENTED BY : MAJOR MAYANK DUDANI
MODERATOR : COL ALOK CHANDRA

2. Patient Details
 56 years old female
 A known case of hypothyroidism and obesity
 Resident of Meerut

3. Chief Complaints (31 Mar 17)
 Yellowish discolouration of eyes , high coloured
urine – 30 days
 Abdominal distension, swelling of both lower
limbs – 07 days
 Altered sensorium – 02 days

4. History of Present Illness
 Initial anorexia , nausea , vomiting followed by
jaundice
 Progressively increasing yellowish discolouration
of eyes , associated with pruritus and
intermitent low grade fever

5. History of present illness
 H / O abdominal distension , swelling of both
lower limbs of 07 days duration
 Altered sensorium in the form of lethargy ,
disorientation and mild confusion of 02 days
duration

6. History (Contd)
 No history of
 Clay coloured stools, pain abdomen , vomiting
 Diarrhoea , constipation , haemetemesis , melena
 Bleeding diathesis in form petechiae, purpura,
ecchymosis,
 Breathlessness, Oliguria, Cough

7. Past History
 Obesity/ Hypothyroidism – on Eltroxin 75 mcg
 No history of jaundice in past
 No history of drug intake, high risk exposure, blood
transfusion, needle stick injury, recent travel
 No past history of - diabetes mellitus
hypertension
IHD
tuberculosis

8. Clinical Summary
 56 yr old female,
 Prodrome followed by Progressive jaundice and
intermittent fever of 30 days duration
 Abdominal distension and swelling of both lower
limbs of 07 days duration
 Altered sensorium of 02 days duration

9. D/D based on history
 Acute viral hepatitis
 Acute on chronic liver failure
 Acute Liver Failure( sub-acute onset)

10. General Physical Examination
 Height –160 cm
 Weight- 88 kgs
 BMI- 35.2 kg/m2
 Afebrile
 Pulse-80/min, regular
 BP-124/72 mm Hg
 RR-20/min

11. General Physical Examination
 No Pallor
 Deep Icterus present
 No clubbing
 No Cyanosis
 No Lymphadenopathy
 Pedal edema +
 Flapping tremor +
 No stigmata of CLD

12. Abdomen:
 Abdomen appeared distended , fullness of flanks
present
Soft, Non tender
No hepato splenomegaly
Flank dullness and shifting dullness present

13.  Respiratory system
Normal
 Cardiovascular system

14. CNS Examination
 HMF
 Drowsy
 Mild confusion present
 Not oriented in time , place and person
 Flapping tremors present
 No focal neurological deficit

15. Investigations
 Hb 10.5 g% TLC 7500/mm3
 P 68 L25 M 4 E3 Platelets-1.0 lac /mm3
 Total bilirubin 26.2mg /dl (D – 16.5)
 AST – 390U/L ALT- 299 U/L ALP - 136 U/L
 Protein – 4.8 g/dl Albumin – 2.1 g/dl
 PT/INR -13/22 Sec & 1.6
 BUN – 34mg/dl creat- 2.07 mg/dl
 Na/K 131meq/L/ & 3.7meq/L

16. Investigations
 Urine RE & ME- Normal
 PS for Malarial parasite
 Dengue serology Negative
 Leptospira serology
 CXR PAView –Normal
 USG Abdomen – Liver normal size with altered echotexture
,Moderate ascitis , GB wall edema
 UGIE – PHG +, no varices
 Eye examination- no KF ring

17. Investigations
 HBsAg / Anti HCV – Negative
 IgM Anti HAV – Negative
 IgM Anti HEV – Positive
 HIV – Non reactive
 ANA- negative
 Ascitic fluid analysis – protein-1.1
albumin – 0.3 (SAAG – 1.8)
WBC – 94 (lymphocytes)
RBC – 340
Culture – no growth
ADA- 12

18. Diagnosis
 Acute on chronic Liver failure
- acute precipitating event - AVH (HEV)
- underlying CLD (? NAFLD associated)

19. Treatment
 Antibiotics: Inj Cefotaxime 2 g IV 8 hrly
 Inj Albumin 20% 100 ml OD
 Syp Lactulose in titrated doses
 Tab Rifaximin 550 mg BD
 Tab UDCA 300 mg BD
 Tab Multivitamin 1 OD
 Salt restricted and high protein diet

20. Course (01 Apr – 10 Apr)]
 Persistent jaundice – serum bilirubin -24.8 mg/dl
 Increasing ascitis - large vol paracentesis done with
Albumin infusions
 Coagulopathy worsened (INR-1.57 to 2.4) – FFP
transfusions / vit K given
 Worsening encephalopahy gd 1 to gd 3 ( Anti NH3
measures stepped up)
 Renal dysfunction – Serum Cr – 2.3mg/dl

21. Course (11 Apr – 20 Apr)
 Patient sensorium improved gradually
 Ascites persisted
 Coagulopathy – INR -1.66
 Renal function better – Cr – 1.2mg/dl

22. Course ( 21 Apr – 04 May )
 Worsening sensorium – Gd 3 to 4 HE
 Progessive renal dysfunction (Cr – 3.0 mg / dl)
 Sepsis with tachypnoea, tachycardia and
development of hypotension followed by
anuria/respiratory failure
 Progressive worsening with cardiac arrest

23. ACLF
 DEFINITION(APASL):
ACLF is an acute hepatic insult manifesting as
jaundice(bil>5mg/dl) and coagulopathy
(INR>1.5) complicated within 4weeks by clinical
ascites and/or encephalopathy in a patient with
previously diagnosed or undiagnosed
CLD/Cirrhosis and associated with high 28day
mortality

24. Prognostic models in ACLF
 APACHE-II SCORE
 MODIFIED SOFA SCORE
 MELD SCORE

25. CLIF -SOFA SCORE

26. a)serum creatinine ≥2 mg/dL or kidney replacement therapy;
b)total bilirubin ≥12; c) International Normalized Ratio ≥2.5 or
platelets 20 × 109/L;
d) use of dopamine, dobutamine, terlipressin, norepinephrine,
epinephrine;
e) PaO/FiO2 ≤200 mg/dL or SpO2/FiO2 ≤214 mg/dL;
f) hepatic encephalopathy grade III or IV. Data from from Moreau et
al.11

27. Liver dialysis/Replacement
therapy in ACLF
 Liver dialysis (prometheus/MARS) improves
bil, HE, HRS in ACLF patients but not survival
 Can be considered as bridge to
transplantation
 Not clear if it is to be considered before or
after onset of sepsis

28. Liver transplantation in ACLF
 ACLF characterized by rapid progression,req of multi
organ support and high short-medium term
mortality(50-90%)
 ACLF patients are susceptible to sepsis/infections
and MOF and early transplant free survival is very
low
 Patients who develop sepsis/infections, renal
dysfunction and require RRT/Mech ventilation are
less likely to undergoTx

29.  Reliable predictors of reversibility in ACLF are not
clearly identified
 Clear consensus guidelines are still lacking for
indications/timing of liver transplant in pts with
ACLF
 Scarcity of donor organ for DDLT with short
window of opportunity
 Lack of enough studies on LDLT in ACLF