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Management of acute-on-chronic liver failure: an algorithmic approach

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Abstract

Acute-on-chronic liver failure (ACLF) is a distinct syndrome of liver failure in a patient with chronic liver disease presenting with jaundice, coagulopathy and ascites and/or hepatic encephalopathy, developing following an acute hepatic insult and associated with high 28-day mortality. The definition though lacks global consensus, excludes patients with known distinct entities such as acute liver failure and those with end-stage liver disease. The initial Systemic Inflammatory Response Syndrome (SIRS) because of cytokine storm in relation to acute insult and/or subsequent development of sepsis due to immunoparalysis leads to extrahepatic organ failure. These cascades of events progress through a ‘Golden Window’ period of about 7 days, subsequent to which majority of the patients develop complications, such as sepsis and extrahepatic organ failure. Prevention of sepsis, support of organs and management of organ failure (commonly hepatic, renal, cerebral, coagulation) and early referral for transplant is crucial. The APASL ACLF research consortium (AARC) liver failure score is a dynamic prognostic model for management decisions and is superior to existing models. Aggressive multidisciplinary approach can lead to a transplant-free survival in nearly half of the cases. The present review provides an algorithmic approach to management of organ failure, sepsis prevention, use of dynamic prognostic models for management decision and is aimed to improve the skills for managing and improving the outcomes of such critically ill patients.

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Abbreviations

AARC:

APASL ACLF research consortium

AD:

Acute decompensation

ACLF:

Acute-on-chronic liver failure

CARS:

Compensated anti-inflammatory response syndrome

DAMP:

Damage associated molecular pattern

ESLD:

End stage liver disease

PAMP:

Pathogen Associated Molecular Pattern

SIRS:

Systemic inflammatory response syndrome

SAH:

Severe alcoholic hepatitis

References

  1. Sarin S, Chandan K, Zaigham A, APASL ACLF working partyl, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int 2014;8:453–471

    Article  Google Scholar 

  2. Sarin SK, Choudhury A. Acute-on-chronic liver failure. Curr Gastroenterol Rep 2016;18(12):61 (PMID: 27747458)

    Article  Google Scholar 

  3. Sarin SK, Choudhury A. Acute-on-chronic liver failure: terminology, mechanisms and management. Nat Rev Nat Rev Gastroenterol Hepatol 2016;13(3):131–149

    Article  CAS  Google Scholar 

  4. Choudhury A, Jindal A, Sarin SK, for the APASL ACLF Working Party et al. Liver failure determines the outcome in patients of Acute-on-Chronic Liver Failure (ACLF)-comparison of APASLACLF Research Consortium (AARC) and CLIF-SOFA model. Hepatol Int 2017;11(5):461–471.

    Article  CAS  Google Scholar 

  5. Choudhury AK, Sharma M, Mehtab M, Sarin SK, for APASL ACLF Working party, et al. The decision for liver transplant in acute-on-chronic liver failure (ACLF)-first week is the crucial period-analysis of the APASL ACLF Research Consortium (AARC) prospective data of 1021 patients. J Hepatol 2016;64:151

    Article  Google Scholar 

  6. Sarin SK, Kumar A, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int 2009;3:269–282

    Article  Google Scholar 

  7. Moreau R, Jalan R, Gines P, et al. Acute on chronic liver failure is a distinct syndrome that develops in patients with acute decompensation of cirrhosis. Gastroenterology 2013;144:1426–1437

    Article  Google Scholar 

  8. Choudhury A, Sharma M, Sarin SK, for APASL ACLF Working party, et al. Etiology, time frame and spectrum of decompensation in 6236 patients of cirrhosis liver across Asia: a multinational study from APASL ACLF Research Consortium (AARC). J Hepatol 2017;66:S63–S94

    Article  Google Scholar 

  9. Arroyo V, Moreau R, Jalan R, Ginès P, EASL-CLIF Consortium CANONIC Study. Acute-on-chronic liver failure: a new syndrome that will re-classify cirrhosis. J Hepatol 2015;62(1 Suppl):S131–S143. https://doi.org/10.1016/j.jhep.2014.11.045

    Article  PubMed  Google Scholar 

  10. Hou W, Li J, Wang JH, Meng QH. Carbohydrate-predominant LES is associated with increases in fasting carbohydrate oxidation, REE and reductions in fat oxidation in adults with ACLF. Therapeutic strategies utilizing LES may promote improved nutritional status in adults with ACLF. Eur J Clin Nutr 2013;67:1251–126

    Article  CAS  Google Scholar 

  11. Krenitsky J. Nutrition for patients with hepatic failure. Pract Gastroenterol 2003;6:23–42

    Google Scholar 

  12. Zhang B, Wei G, Li R, Wang Y, Yu J, Wang R, Xiao H, et al. n-3 fatty acid-based parenteral nutrition improves postoperative recovery for cirrhotic patients with liver cancer: a randomized controlled clinical trial. Clin Nutr 2017;36(5):1239–1244. https://doi.org/10.1016/j.clnu.2016.08.002

    Article  CAS  PubMed  Google Scholar 

  13. Garg H, Sarin SK, Kumar M, Garg V, Sharma BC, Kumar A. Tenofovir improves the outcome in patients with spontaneous re- activation of hepatitis B presenting as acute-on-chronic liver failure. Hepatology 2011;53:774–780

    Article  CAS  Google Scholar 

  14. Jindal A, Kumar M, Sarin SK. A randomized comparative open label trial of tenofovir monotherapy versus tenofovir plus telbuvidine dual therapy in spontaneous reactivation of hepatitis B. J Viral Hepat 2015;22(Suppl. 2):1–18

    Google Scholar 

  15. Li H, Xia Q, Zeng B, Li ST, Liu H, Li Q, Li J, et al. Submassive hepatic necrosis distinguishes HBV-associated acute on chronic liver failure from cirrhotic patients with acute decompensation. J Hepatol 2015;63(1):50–59. https://doi.org/10.1016/j.jhep.2015.01.029 (Epub 2015 Jan 31)

    Article  PubMed  Google Scholar 

  16. Louvet A, Mathurin P. Alcoholic liver disease: mechanisms of injury and targeted treatment. Nat Rev Gastroenterol Hepatol 2015. https://doi.org/10.1038/.nrgastro.2015.35

    Article  PubMed  Google Scholar 

  17. Mathurin P, et al. Corticosteroids improve short-term survival in patients with severe alcoholic hepatitis: meta-analysis of individual patient data. Gut 2011;60:255–60

    Article  CAS  Google Scholar 

  18. Louvet A, Wartel F, Castel H, Mathurin P. Infection in patients with severe alcoholic hepatitis treated with steroids: early response to therapy is the key factor. Gastroenterology 2009;137:541–548

    Article  CAS  Google Scholar 

  19. Mathurin P, Moreno C, Samuel D, Pruvot FR, Vallée JC. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med 2011;365:1790–800

    Article  CAS  Google Scholar 

  20. Shasthry SM, Sharma M, Sarin SK. Efficacy of granulocyte colony stimulating factor in the management of steroid non-responsive severe alcoholic hepatitis—a double blind randomized control trial. J Hepatol 2017;66(1):S79–S80 https://doi.org/10.1016/s0168-8278(17)30422-1.

    Article  Google Scholar 

  21. Mambro AJ, et al. In vitro steroid resistance correlates with out- come in severe alcoholic hepatitis. Hepatology 2011;53:1316–1322

    Article  Google Scholar 

  22. Philips CA, Pande A, Shasthry SM, Choudhary A, Sarin SK, et al. Healthy donor fecal microbiota transplantation in steroid ineligible severe alcoholic hepatitis—a pilot study. Clin Gastroenterol Hepatol 2016. https://doi.org/10.1016/j.cgh.2016.10.029 (Epub ahead of print)

    Article  PubMed  Google Scholar 

  23. Louvet A, Mathurin P. Alcoholic liver disease: mechanisms of injury and targeted treatment. Nat Rev Gastroenterol Hepatol 2015. https://doi.org/10.1038/.nrgastro.2015.35

    Article  PubMed  Google Scholar 

  24. Yeoman AD, O’Grady JG, Heneghan MA. Prognosis of acute severe autoimmune hepatitis (AS-AIH): the role of corticosteroids in modifying outcome. J Hepatol 2014. https://doi.org/10.1016/j.jhep.2014.05.021

    Article  PubMed  Google Scholar 

  25. Nakao M, Nakayama N, Uchida Y, Tomiya T, Ido A, Sakaida I, Yokosuka O, et al. Nationwide survey for acute liver failure and late-onset hepatic failure in Japan. J Gastroenterol 2017. https://doi.org/10.1007/s00535-017-1394-2 (Epub ahead of print)

    Article  PubMed  Google Scholar 

  26. Anand L, Choudhury A, Bihari C, Sharma BC, Sarin SK, APASL ACLF working party. Flare of Autoimmune Hepatitis as a cause of acute on chronic liver failure and its response to steroid therapy. Hepatology 2017;(Suppl):661–662. (AASLD abstract).

  27. Yeoman AD, Westbrook RH, Portmann C, O’Grady OJ, Harrison PM, Heneghan MA. Early predictors of corticosteroid treatment failure in icteric presentations of autoimmune hepatitis. Hepatology 2011;53:926–934

    Article  Google Scholar 

  28. Sonthalia N, Rathi PM, Jain SS, Surude RG, Mohite AR, Pawar SV, Contractor Q. Natural history and treatment outcomes of severe autoimmune hepatitis. J Clin Gastroenterol 2017;51(6):548–556 https://doi.org/10.1097/MCG.0000000000000805.

    Article  PubMed  Google Scholar 

  29. Larsen FS, Vainer B, Bjerring PN, Hansen BA. Low-dose tacrolimus ameliorates liver inflammation and fibrosis in steroid refractory autoimmune hepatitis. World J. Gastroenterol 2007;13:3232–3236

    Article  CAS  Google Scholar 

  30. Hennes EM, et al. Mycophenolate mofetil as second line therapy in autoimmune hepatitis? Am J. Gastroenterol 2008;103:3063–3070

    Article  CAS  Google Scholar 

  31. Devarbhavi H, Choudhury AK, Reddy VV, Sarin SK, APASL ACLF Working party. Acute-on-chronic Liver Failure secondary to drugs: causes, out- come and predictors of mortality. J Hepatol 2016;64:S232 https://doi.org/10.1016/S0168-8278(16)00220-8 (EASL Abstract 2016 in press)

    Article  Google Scholar 

  32. Garg H, Kumar A, Garg V, Sharma P, Sharma BC, Sarin SK. Clinical profile and predictors of mortality in patients of acute- on-chronic liver failure. Dig Liver Dis 2012;44(2):166–1671

    Article  Google Scholar 

  33. Selva Rajoo A, Lim SG, Phyo WW, Tun T, Dan YY, Lee YM, Low HC, et al. Acute-on-chronic liver failure in a multi-ethnic Asian city: a comparison of patients identified by Asia-Pacific Association for the Study of the Liver and European Association for the Study of the Liver definitions. World J Hepatol 2017;9(28):1133–1140. https://doi.org/10.4254/wjh.v9.i28.1133

    Article  Google Scholar 

  34. Vyas TS, Maiwall R, Jinadal A, Sarin SK. Goal directed ammonia lowering therapy in acute on chronic liver failure (ACLF) with hepatic encephalopathy (HE): a randomized trial (clinicaltrials.gov identifier: NCT02321371). Hepatol J 2017;7(1):S19–S2 (in press).

    Article  Google Scholar 

  35. Maiwall R, Kumar S, Vashishtha C, Kumar M, Garg H, Nayak SL, et al. Acute kidney injury (AKI) in patients with Acute-on-chronic liver failure (ACLF) is different from patients with cirrhosi. Hepatology 2015;58(4 Suppl):36A–91A

    Google Scholar 

  36. Jindal A, Bhadoria AS, Maiwall R, Sarin SK. Evaluation of acute kidney injury and its response to terlipressin in patients with acute- on-chronic liver failure. Liver Int. 2015. https://doi.org/10.1111/liv.12895.

    Article  PubMed  Google Scholar 

  37. Maiwall R, Choudhury AK, Devarbhavi H, ShivK, Sarin K, APASL ACLF Working Party. Dynamic AARC-AKI score determines extra- renal organ failures and bacterial infection in patients with acute on chronic liver failure. Hepatology 2017; 661 (Suppl) (AASLD abstract)

  38. Maiwall R, Chandel SS, Wani Z, Kumar S, Sarin SK. SIRS at admission is a predictor of AKI development and mortality in hospitalized patients with severe alcoholic hepatitis. Dig Dis Sci 2016;61(3):920–929

    Article  CAS  Google Scholar 

  39. Arora V, Maiwall R, Choudhury A, Jain P, Kumar G, Sarin SK. Terlipressin is superior to Noradrenaline in the management of acute kidney injury (AKI) in patients with ACLF. Terlipressin is superior to Noradrenaline in the management of acute kidney injury (AKI) in patients with ACLF. J Hepatol 2017;66(1):563

    Article  Google Scholar 

  40. Slack AJ, et al. Ammonia clearance with haemofiltration in adults with liver disease. Liver Int 2014;34:42–48

    Article  CAS  Google Scholar 

  41. Gonwa TA, Wadei HM. The challenges of providing renal replacement therapy in decompensated liver cirrhosis. Blood Purif 2012;33:144–148

    Article  Google Scholar 

  42. Cardoso FS, Gottfried M, Tujios S, Olson JC, Karvellas CJ, US Acute Liver Failure Study Group. Continuous renal replacement therapy is associated with reduced serum ammonia levels and mortality in acute liver failure. Hepatology 2017. https://doi.org/10.1002/hep.29488

    Article  PubMed  Google Scholar 

  43. Choudhury A, Kumar M, Sharma BC, Maiwall R, Pamecha V, Moreau R, Chawla YK. Systemic inflammatory response syndrome in acute on chronic liver failure- relevance of ‘Golden Window’—a prospective study. J Gastroenterol Hepatol 2017. https://doi.org/10.1111/jgh.13799 (Epub ahead of print PMID: 28374414)

    Article  PubMed  Google Scholar 

  44. O’Brien AJ, et al. Immunosuppression in acutely decompensated cirrhosis is mediated by prostaglandin E2. Nat Med. 2014;20:518–523

    Article  Google Scholar 

  45. Choudhury A, Kedarisetty CK, Vashishtha C, Saini D, Kumar S, Maiwall R, et al. A randomized trial comparing terlipressin and noradrenaline in patients with cirrhosis and septic shock. Liver Int 2016. https://doi.org/10.1111/liv.13252

    Article  PubMed  Google Scholar 

  46. Russell JA, Walley KR, Singer J, Gordon AC, Hébert PC, Cooper DJ, Holmes CL, et al. Vasopressin versus norepinephrine infusion in patients with septic shock. N Engl J Med 2008;358(9):877–887 (PMID: 18305265)

    Article  CAS  Google Scholar 

  47. Levesque E, Saliba F, Ichaï P, Samuel D. Outcome of patients with cirrhosis requiring mechanical ventilation in ICU. J Hepatol 2014;60(3):570–578. https://doi.org/10.1016/j.jhep.2013.11.012 (Epub 2013 Nov 23)

    Article  CAS  PubMed  Google Scholar 

  48. Knaak J, McVey M, Bazerbachi F, Goldaracena N, Spetzler V, Selzner N, et al. Liver transplantation in patients with end-stage liver disease requiring intensive care unit admission and intubation. Liver Transpl. 2015;21(6):761–767. https://doi.org/10.1002/lt.24115 (Epub 2015 Apr 23)

    Article  PubMed  Google Scholar 

  49. Garg H, Kumar A, Sharma BC, Sarin SK, et al. Hepatic and systemic hemodynamic derangements predict early mortality and recovery in patients with acute-on-chronic liver failure. J Gastroenterol Hepatol 2013;28:1361–7

    Article  Google Scholar 

  50. Kainth S, Sharma MK, Choudhury AK, Anand L, Jindal A, Kumar G, Jain P, et al. Efficacy and safety of carvedilol in patients of acute-on-chronic liver failure with small or no esophageal varices – a placebo control open label randomised trial (NCT02583698). Hepatology 2017; 66(1 Suppl). (AASLD abstract)

  51. Agrawal S, Duseja A, Gupta T, Dhiman RK, Chawla Y. Simple organ failure count versus CANONIC grading system for predicting mortality in acute-on-chronic liver failure. J Gastroenterol Hepatol 2015;30(3):575–581

    Article  Google Scholar 

  52. Kalambokis G, Manousou P, Patch D, Burroughs AK. Transjugular liver biopsy-indications, adequacy, quality of specimens, and complications—a systematic review. J Hepatol 2007;47:284–294

    Article  Google Scholar 

  53. Rastogi A, Kumar A, Gondal R, Sarin SK, et al. Liver histology as predictor of outcome in patients with acute-on-chronic liver failure (ACLF). Virchows Arch 2011;459:121–127

    Article  Google Scholar 

  54. Li H, et al. Submassive hepatic necrosis distinguishes HBV-associated acute on chronic liver failure from cirrhotic patients with acute decompensation. J Hepatol 2015;63:50–59

    Article  Google Scholar 

  55. Chan CA, Fan ST, Lo CM, Liu CL, Chan SC, Ng KK, et al. Liver transplantation for acute-on-chronic liver failure. Hepatol Int 2009;3:571–581

    Article  Google Scholar 

  56. Xue R, Duan Z, Liu H, Chen L, Yu H, Ren M, Zhu Y, et al. A novel dynamic model for predicting outcome in patients with hepatitis B virus related acute-on-chronic liver failure. Oncotarget 2017;8(65):108970–108980. https://doi.org/10.18632/oncotarget.22447

    Article  PubMed  PubMed Central  Google Scholar 

  57. Song DS, Kim TY, Kim DJ, Kim HY, Sinn DH, Yoon EL, Kim CW, et al. Validation of prognostic scores to predict short-term mortality in patients with acute-on-chronic liver failure. J Gastroenterol Hepatol 2017. https://doi.org/10.1111/jgh.13991

    Article  PubMed  Google Scholar 

  58. Gao F, Sun L, Ye X, Liu Y, Liu H, Geng M, Li X, et al. Development and validation of a prognostic model for acute-on-chronic hepatitis B liver failure. Eur J Gastroenterol Hepatol 2017;29(6):669–678. https://doi.org/10.1097/meg.0000000000000854

    Article  PubMed  Google Scholar 

  59. Pamecha V, Kumar S, Bharathy KG. Liver transplantation in acute on chronic liver failure: challenges and an algorithm for patient selection and management. Hepatol Int. 2015;9(4):534–542. https://doi.org/10.1007/s12072-015-9646-9 (Epub 2015 Jul 10)

    Article  PubMed  Google Scholar 

  60. Gustot T, Fernandez J, Garcia E, for CANONIC Study Investigators of the EASL-CLIF Consortium, et al. Clinical course of acute-on-chronic liver failure syndrome and effects on prognosis. Hepatology 2015;62(1):243–252

    Google Scholar 

  61. Wong RJ, Aguilar M, Gish RG, Cheung R, Ahmed A. The impact of pretransplant hepatic encephalopathy on survival following liver transplantation. Liver Transpl 2015;21:873–880

    Article  Google Scholar 

  62. Staufer K, Roedl K, Kivaranovic D, Drolz A, Horvatits T, Rasoul-Rockenschaub S, Zauner C, et al. Renal replacement therapy in critically ill liver cirrhotic patients-outcome and clinical implications. Liver Int 2017;37(6):843–850. https://doi.org/10.1111/liv.13389 (Epub 2017 Apr 5)

    Article  PubMed  Google Scholar 

  63. Cheng CH, Lee CF, Soong RS, Wu TH, Chan KM, Chou HS, Wu TJ, et al. Risk factors and clinical outcomes of ventilator-associated pneumonia in patients on the liver transplant waiting list. Transpl Proc 2012;44(3):762–764

    Article  Google Scholar 

  64. Moon DB, Lee SG, Kang WH, Song GW, Jung DH, Park GC, Cho HD, et al. Adult living donor liver transplantation for acute-on-chronic liver failure in high- model for end-stage liver disease score patients. Am J Transpl 2017;17(7):1833–1842 (PMID: 28097804]-64).

    Article  Google Scholar 

  65. Putignano A, Gustot T. New concepts in acute-on-chronic liver failure: Implications for liver transplantation. Liver Transpl 2017;23(2):234–243. https://doi.org/10.1002/lt.24654 (Epub 2017 Jan 6. Review. PMID: 27750389-65)

    Article  PubMed  Google Scholar 

  66. Artru F, Louvet A, Ruiz I, et al. Liver transplantation in the most severely ill cirrhotic patients: a multicenter study in acute-on-chronic liver failure grade 3. J Hepatol. 2017. https://doi.org/10.1016/j.jhep.2017.06.009 (Epub ahead of print)

    Article  PubMed  Google Scholar 

  67. Reddy MS, Rajalingam R, Rela M. Liver transplantation in acute-on-chronic liver failure: lessons learnt from acute liver failure setting. Hepatol Int 2015;9(4):508–513. https://doi.org/10.1007/s12072-014-9603-z (Epub 2015 Jan)

    Article  PubMed  Google Scholar 

  68. Maiwall R, Maras JS, Nayak S, Sarin SK. Liver dialysis in acute- on-chronic liver failure: current and future 3 perspectives. International 2014;8(2 Supplement):505–513

    Google Scholar 

  69. Wan YM, Li YH, Xu ZY, Yang J, Yang LH, Xu Y, Yang JH. Therapeutic plasma exchange versus double plasma molecular absorption system in hepatitis B virus-infected acute-on-chronic liver failure treated by entecavir: a prospective study. J Clin Apher. 2017;32(6):453–461. https://doi.org/10.1002/jca.21535 (Epub 2017 Mar 17)

    Article  PubMed  Google Scholar 

  70. Chen JJ, Huang JR, Yang Q, Xu XW, Liu XL, Hao SR, Wang HF, et al. Plasma exchange-centered artificial liver support system in hepatitis B virus-related acute-on-chronic liver failure: a nationwide prospective multicenter study in China. Hepatobiliary Pancreat Dis Int 2016;15(3):275–281

    Article  Google Scholar 

  71. Kribben A, Gerken G, Haag S, et al. Effects of fractionated plasma separation and adsorption on survival in patients with acute-on- chronic liver failure. Gastroenterology. 2012;142:782.e3–789.e3

    Article  Google Scholar 

  72. Banares R, Nevens F, Larsen FS, et al. Extracorporeal albumin dialysis with the molecular adsorbent recirculating system in acute-on-chronic liver failure: the RELIEF trial. Hepatology 2013;57:1153–1162

    Article  CAS  Google Scholar 

  73. Vaid A, Chweich H, Balk EM, Jaber BL. Molecular adsorbent recirculating system as artificial support therapy for liver failure: a meta-analysis. ASAIO J 2012;58(1):51–59

    Article  CAS  Google Scholar 

  74. Li H, Chen HS, Nyberg SL. Extracorporeal liver support and liver transplant for patients with acute-on-chronic liver failure. Semin Liver Dis 2016;36(2):153–160. https://doi.org/10.1055/s-0036-1583197 (Epub 2016 May 12 PMID: 27172357)

    Article  PubMed  Google Scholar 

  75. Zheng Z, Li X, Li Z, Ma X. Artificial and bioartificial liver support systems for acute and acute-on-chronic hepatic failure: A meta-analysis and meta-regression. Exp Ther Med 2013;6(4):929–936 (Epub 2013 Jul PubMedPMID: 24137292; PubMed Central PMCID: PMC3797301)

    Article  Google Scholar 

  76. Stutchfield BM, Simpson K, Wigmore SJ. Systematic review and meta-analysis of survival following extracorporeal liver support. Br J Surg 2011;98(5):623–631. https://doi.org/10.1002/bjs.7418

    Article  CAS  PubMed  Google Scholar 

  77. Zheng Z, Li X, Li Z, Ma X. Artificial and bioartificial liver support systems for acute and acute-on-chronic hepatic failure: a meta-analysis and meta-regression. Exp Ther Med 2013;6(4):929–936

    Article  Google Scholar 

  78. Pless G, Sauer IM. Bioartificial  liver:  current  status. Transpl Proc 2005;37:3893–3895

    Article  CAS  Google Scholar 

  79. Michalopoulos GK. Hepatostat: Liver regeneration and normal liver tissue maintenance. Hepatology 2017;65(4):1384–1392. https://doi.org/10.1002/hep.28988

    Article  PubMed  Google Scholar 

  80. Maiwal R, Kumar A, Sarin SK. Liver regeneration during acute-on-chronic liver failure using growth factors: in vivo or ex vivo indulgence of bone marrow? Gastroenterology 2013;145(4):901–904. https://doi.org/10.1053/j.gastro.2013.08.031 (Epub 2013 Aug 21 PubMed PMID: 23973679)

    Article  PubMed  Google Scholar 

  81. Zhang Z, Wang FS. Stem cell therapies for liver failure and cirrhosis. J Hepatol 2013;59(1):183–185 (PMID:23353868)

    Article  Google Scholar 

  82. Garg V, Garg H, Khan A, Sarin SK, et al. Granulocyte-colony stimulating factor mobilizes CD34+ cells and improves survival of patients with acute-on-chronic liver failure. Gastroenterology 2012;142:505–512

    Article  CAS  Google Scholar 

  83. Singh V, Sharma AK, Sharma N, Sharma R. Granulocyte colony- stimulating factor in severe alcoholic hepatitis : a randomized pilot study. Am J Gastroenterol 2014;109:1417–1423

    Article  CAS  Google Scholar 

  84. Duan XZ, Liu FF, Tong JJ, Hu JH. Granulocyte-colony stimulat- ing factor therapy improves survival in patients with hepatitis B virus-associated acute on- chronic liver failure. World J Gastroenterol 2013;19(7):1104–1110

    Article  CAS  Google Scholar 

  85. Kedarisetty CK, Anand L, Bhatia V, Sarin SK. Combination of granulocyte colony-stimulating factor and erythropoietin im- proves outcomes of patients with decompensated cirrhosis. Gastroenterology 2015;148(7):1362.e7–1370.e7

    Article  Google Scholar 

  86. Dhawan A, Puppi J, Hughes RD, Mitry RR. Human hepatocyte transplantation: current experience and future challenges. Nat Rev Gastroenterol Hepatol 2010;7(5):288–298. https://doi.org/10.1038/nrgastro.2010.44 (Epub 2010 Apr 6)

    Article  PubMed  Google Scholar 

  87. Wang F, Zhou L, Ma X, Ma W, Wang C, Lu Y, Chen Y, et al. Monitoring of intrasplenic hepatocyte transplantation for acute-on-chronic liver failure: a prospective five-year follow-up study. Transpl Proc 2014;46(1):192–198

    Article  CAS  Google Scholar 

  88. Shi M, Zhang Z, Jin L, Liu Z, Wang FS, et al. Human mesenchymal stem cell transfusion is safe and improves liver function in acute-on-chronic liver failure patients. Stem Cells Transl Med 2012;1(10):725–731

    Article  CAS  Google Scholar 

  89. Piscaglia AC, Arena V, Passalacqua S, Gasbarrini A. A case of granulocyte-colony stimulating factor/plasmapheresis-induced activation of granulocyte-colony stimulating factor-positive hepatic progenitors in acute-on-chronic liver failure. Hepatology 2015. https://doi.org/10.1002/hep.27708

    Article  PubMed  Google Scholar 

  90. Nikeghbalian S, Pournasr B, Aghdami N, Rasekhi A, Geramizadeh B, Hosseini Asl SM, Ramzi M, et al. Autologous transplantation of bone marrow-derived mononuclear and CD133(+) cells in patients with decompensated cirrhosis. Arch Iran Med 2011;14(1):12–17. https://doi.org/10.11141/AIM.004

    Article  PubMed  Google Scholar 

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Acknowledgements

Authors are grateful to R. K. Gulati for his intellectual inputs and proof reading.

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  1. Department of Hepatology and Liver Transplant, Institute of Liver and Biliary Sciences, D-1, VasantKunj, New Delhi, 110070, India

    Shiv Kumar Sarin & Ashok Choudhury

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AC drafted the manuscript and designed the sections and designed the figures. SKS edited the manuscript, revised the sections and prepared the final version.

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Correspondence to Shiv Kumar Sarin.

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Shiv K Sarin and Ashok Choudhury declare that they have no conflict of interest.

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Sarin, S.K., Choudhury, A. Management of acute-on-chronic liver failure: an algorithmic approach. Hepatol Int 12, 402–416 (2018). https://doi.org/10.1007/s12072-018-9887-5

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