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      Acute-on-chronic liver failure

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          Abstract

          Acute-on-chronic liver failure (ACLF) is an increasingly recognized distinct disease entity encompassing an acute deterioration of liver function in patients with chronic liver disease. Although there are no widely accepted diagnostic criteria for ACLF, the Asia.Pacific Association for the Study of the Liver (APASL) and the American Association for the Study of Liver Disease and the European Association for the Study of the Liver (AASLD/EASL) consensus definitions are commonly used. It is obvious that the APASL and the AASLD/EASL definitions are based on fundamentally different features. Two different definitions in two different parts of the world hamper the comparability of studies. Recently, the EASL-Chronic Liver Failure Consortium proposed new diagnostic criteria for ACLF based on analyses of patients with organ failure. There are areas of uncertainty in defining ACLF, such as heterogeneity of ACLF, ambiguity in qualifying underlying liver disease, argument for infection or sepsis as a precipitating event, etc. Although the exact pathogenesis of ACLF remains to be elucidated, alteration of host response to injury, infection, and unregulated inflammation play important roles. The predisposition, infection/inflammation, response, organ failure (PIRO) concept used for sepsis might be useful in describing the pathophysiology and clinical categories for ACLF. Treatment strategies are limited to organ support but better understanding of the pathophysiology is likely to lead to discovery of novel biomarkers and therapeutic strategies in the future.

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          Most cited references 25

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          American College of Chest Physicians/Society of Critical Care Medicine Consensus Conference: definitions for sepsis and organ failure and guidelines for the use of innovative therapies in sepsis.

          (1992)
          To define the terms "sepsis" and "organ failure" in a precise manner. Review of the medical literature and the use of expert testimony at a consensus conference. American College of Chest Physicians (ACCP) headquarters in Northbrook, IL. Leadership members of ACCP/Society of Critical Care Medicine (SCCM). An ACCP/SCCM Consensus Conference was held in August of 1991 with the goal of agreeing on a set of definitions that could be applied to patients with sepsis and its sequelae. New definitions were offered for some terms, while others were discarded. Broad definitions of sepsis and the systemic inflammatory response syndrome were proposed, along with detailed physiologic variables by which a patient could be categorized. Definitions for severe sepsis, septic shock, hypotension, and multiple organ dysfunction syndrome were also offered. The use of severity scoring methods were recommended when dealing with septic patients as an adjunctive tool to assess mortality. Appropriate methods and applications for the use and testing of new therapies were recommended. The use of these terms and techniques should assist clinicians and researchers who deal with sepsis and its sequelae.
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            Management of Sepsis

            New England Journal of Medicine, 355(16), 1699-1713
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              Risk of venous thromboembolism in patients with liver disease: a nationwide population-based case-control study.

              It is known that liver disease can cause an imbalance in the coagulation system, but available data on liver disease and risk of venous thromboembolism are conflicting. We examined the risk of venous thromboembolism in patients hospitalized with liver diseases. We conducted a nationwide Danish case-control study of incident cases of venous thromboembolism from 1980 to 2005 using population-based data from the National Registry of Patients, and from the Civil Registration System. We used conditional logistic regression to compute the relative risk of venous thromboembolism in patients with liver disease compared to population controls. We then excluded patients with known malignancy (diagnosed either before or up to 3 months after the venous thromboembolism) or fractures, trauma, surgery, or pregnancy within 90 days before the venous thromboembolism to estimate the risk associated with unprovoked venous thromboembolism. A total of 99,444 patients with venous thromboembolism and 496,872 population controls were included in the study. Patients with liver disease had a clearly increased relative risk of venous thromboembolism, varying from 1.74 (95% CI, 1.54-1.95) for liver cirrhosis to 1.87 (95% CI, 1.73-2.03) for non-cirrhotic liver disease. The risks were higher for deep venous thrombosis compared with pulmonary embolism. In the analysis, restricted to 67,519 patients with unprovoked venous thromboembolism and 308,614 population controls, we found slightly higher relative risks: 2.06 (95% CI, 1.79-2.38) for liver cirrhosis and 2.10 (95% CI, 1.91-2.31) for non-cirrhotic liver disease. Patients with liver disease have a substantially increased risk of venous thromboembolism.
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                Author and article information

                Journal
                Clin Mol Hepatol
                Clin Mol Hepatol
                CMH
                Clinical and molecular hepatology
                The Korean Association for the Study of the Liver
                2287-2728
                2287-285X
                December 2013
                28 December 2013
                : 19
                : 4
                : 349-359
                Affiliations
                [1 ]Department of Internal Medicine, Hanyang University Guri Hospital, Hanyang University College of Medicine, Guri, Korea.
                [2 ]Department of Internal Medicine, Hallym University College of Medicine, Chuncheon, Korea.
                Author notes
                Corresponding author: Dong Joon Kim. Department of Internal Medicine, Hallym University Chuncheon Sacred Heart Hospital, Sakju-ro 77, Chuncheon 200-704, Korea. Tel. +82-33-240-5646, Fax. +82-33-241-8064, djkim@ 123456hallym.ac.kr
                Article
                10.3350/cmh.2013.19.4.349
                3894433
                c2c3c852-1946-4611-862d-623b40f3db43
                Copyright © 2013 by The Korean Association for the Study of the Liver

                This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License ( http://creativecommons.org/licenses/by-nc/3.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.

                Categories
                Review

                Gastroenterology & Hepatology

                acute-on-chronic liver failure, liver cirrhosis, liver failure

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