This document summarizes a mortality meeting discussing a 56-year-old female patient with hypothyroidism and obesity who presented with jaundice, abdominal distension, and altered sensorium. Based on her history, physical exam findings, and test results, she was diagnosed with acute-on-chronic liver failure precipitated by hepatitis E virus infection, with an underlying chronic liver disease likely non-alcoholic fatty liver disease. Her condition deteriorated over her hospital stay despite treatment and she eventually suffered cardiac arrest. The meeting discussed definitions of acute-on-chronic liver failure, prognostic models, liver support therapies, and challenges regarding liver transplantation for patients with acute-on-chronic liver failure.

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