Clinical Features and Natural History of Acute-on-Chronic Liver Failure in Korean Patients With Chronic Liver Disease
Clinical Features and Natural History of Acute-on-Chronic Liver Failure in Korean Patients With Chronic Liver Disease
Chronic liver disease including liver cirrhosis is still associated with high mortality,
 although advancement of medical management and transplantation. Acute-on-chronic liver
 failure (ACLF) refers to condition of previously stable chronic liver disease with occurrence
 of an acute insult resulting in rapid deterioration of liver function and subsequent
 decompensation. This condition is different from liver cirrhosis (chronic hepatic
 decompensation) in terms of having more chance of recovery with management before acute
 deterioration, although it shows high short-term mortality. Thus, earlier recognition and
 intensive management are important for this condition. However, the definition or diagnostic
 criteria is unclear and the natural course of this condition is not definitely investigated.
 The aim of this study is to establish the natural course of ACLF in Korean patients.
Chronic liver disease including liver cirrhosis is still associated with high mortality,
 although advancement of medical management and transplantation. Acute-on-chronic liver
 failure (ACLF) refers to condition of previously stable chronic liver disease with occurrence
 of an acute insult resulting in rapid deterioration of liver function and subsequent
 decompensation. Various factors could be a precipitating factor of ACLF. This condition is
 different from liver cirrhosis (chronic hepatic decompensation) in terms of having more
 chance of recovery with management before acute deterioration, although it shows high
 short-term mortality. Thus, earlier recognition and intensive management are important for
 this condition. However, the definition or diagnostic criteria is unclear and the natural
 course of this condition is not definitely investigated. The aim of this study is to
 establish the common etiology, symptom and natural course of ACLF in Korean patients.
Inclusion Criteria:

 -  Chronic liver disease: Chronic hepatitis B, Chronic hepatitis C, Alcoholic liver
 disease, Biopsy proven or clinically diagnosed liver cirrhosis, Other chronic liver
 diseases including non-alcoholic fatty liver disease, primary biliary cirrhosis,
 autoimmune hepatitis, hemochromatosis, Wilson's disease, a-1 antitrypsin deficiency,
 and cryptogenic causes.

 -  Acute deterioration of liver function: more than one of the below criteria

 1. development of new ascites within 4 weeks or re-emergence of ascites who have
 previous well controlled ascites (greater than or equal to grade 2 or 3;
 International ascites club criteria)

 2. development of hepatic encephalopathy

 3. development of gastrointestinal hemorrhage

 4. development of jaundice (serum bilirubin greater than or equal to 3mg/dl)

 5. development of bacterial infection

 -  spontaneous bacteremia: positive blood cultures without a source of infection

 -  spontaneous bacterial peritonitis: ascitic fluid polymorphonuclear cells >250/µL

 -  lower respiratory tract infections: new pulmonary infiltrate in the presence of: i) at
 least one respiratory symptom (cough, sputum production, dyspnea, pleuritic pain) with
 ii) at least one finding on auscultation (rales or crepitation) or one sign of
 infection (core body temperature >38_C or less than 36_C, shivering, or leukocyte
 count >10,000/mm3 or <4,000/mm3) in the absence of antibiotics

 -  Clostridium difficile Infection: diarrhea with a positive C. difficile assay

 -  bacterial entero-colitis: diarrhea or dysentery with a positive stool culture for
 Salmonella, Shigella, Yersinia, Campylobacter, or pathogenic E. coli;

 -  soft-tissue/skin Infection: fever with cellulitis

 -  urinary tract infection (UTI): urine white blood cell >15/high-power field with either
 positive urine gram stain or culture;

 -  intra-abdominal infections: diverticulitis, appendicitis, cholangitis, etc.

 -  other infections not covered above;

 -  fungal infections as a separate category.

 Exclusion Criteria:

 -  Patients who do not have chronic liver disease

 -  Patients who have hepatocellular carcinoma

 -  Patients who admitted for extrahepatic manifestations

 -  Patients who have HIV infection

 -  Patients who admitted for symptomatic control of chronic liver disease, other than
 acute deterioration of liver function