International research association determines three forms of “acute decompensated liver cirrhosis”
by Adolf Albus
(27.08.2020) If the body can no longer compensate for the gradual failure of the liver as a result of liver cirrhosis, there is a risk of acute decompensation of the liver cirrhosis. In some patients, this quickly develops into an often fatal acute-on-chronic liver failure, in which other organs such as the kidney or brain fail.
In a study funded by the EF Clif Foundation, an international team of researchers led by Prof. Jonel Trebicka from the Frankfurt University Hospital found out which patients are particularly at risk. The scientists have thus laid the basis for the development of preventive therapies to prevent acute-on-chronic liver failure. (Journal of Hepatology, DOI 10.1016 / j.jhep.2020.06.013)
Our liver has many functions: it stores nutrients and vitamins, produces glucose, clotting factors and hormones, and breaks down toxins, drugs and alcohol. Chronic heavy alcohol consumption, viruses or other diseases can overload the liver and become chronically ill. If left untreated, end-stage chronic liver disease leads to cirrhosis of the liver, in which liver tissue is converted into connective tissue and the liver is less and less able to perform its tasks. The consequences: the blood’s ability to clot is restricted, toxic metabolic products accumulate, the liver is no longer properly supplied with blood and the blood pressure in the portal vein that supplies the liver rises.
The body tries to compensate for the reduced functions of the liver. For example, as a result of the increased portal pressure, bypass circuits develop through the veins of the esophagus, stomach, and intestines, which expand into varicose veins. If such a compensation is no longer possible at some point as the disease progresses – doctors then speak of acute decompensation of the liver cirrhosis – the situation becomes life-threatening: Tissue fluid (ascites) collects in the abdominal cavity, bacterial infections and internal bleeding occur roughly in the esophagus. Difficulty concentrating, mood swings or sleepiness are signs of intoxication of the brain (hepatic encephalopathy), which can lead to hepatic coma.
A Europe-wide clinical study led by Prof. Jonel Trebicka, which was carried out under the umbrella of the European Foundation for the Investigation of Chronic Liver Failure, determined for the first time three clinical course variants of patients who were admitted to hospital with acute decompensation of liver cirrhosis.
The first clinical variant is characterized by high levels of inflammation in the blood, which indicate inflammatory reactions throughout the body. Within three months of being admitted to the hospital, several organs of the body fail: the acute decompensation becomes an “acute-on-chronic liver failure” (ACLF). Therefore, the medical professionals named this variant as pre-ACLF. More than half of the patients die from it, after a year only a third of them are still alive.
The patients of the second clinical course variant do not develop ACLF and have moderate inflammation values, but suffer from a significantly increased portal vein blood pressure. Around 20 percent of them die within the next three months, another 15 percent within the following year. The doctors called this variant “unstable decompensated liver cirrhosis”.
Patients of the third clinical course variant did not show any severe inflammation values or frequent complications. You won’t develop an ACLF in the first three months. However, one in ten of them still dies within a year. The doctors called this variant “stable decompensated liver cirrhosis”.
Study leader Prof. Jonel Trebicka, gastroenterologist and hepatologist at the Medical Clinic I of the University Hospital Frankfurt, explains: “We are now working intensively on developing new diagnostic options, especially for groups of pre-ACLF patients, so that this group can be admitted to hospital identify and initiate countermeasures at an early stage. The development of preventive therapies for the often fatal ACLF is one of our most important research tasks in this context. “
Prof. Dr. Stefan Zeuzem, Dean of the Faculty of Medicine and Director of Medical Clinic I at the University Hospital Frankfurt and co-author of the study, explains: “Liver diseases are one of the main focuses of Medical Clinic I, and we offer numerous special outpatient clinics for patients with acute and chronic liver diseases on. On the one hand, we were able to observe patients for the study. On the other hand, the research results to improve ACLF prevention and therapies very quickly benefit our and all patients. “
The research results are part of the Europe-wide study called PREDICT. The study monitors the clinical course of acute decompensations of liver cirrhosis to find early signs of developing acute-on-chronic liver failure (ACLF). The study is funded by the European Foundation for the Study of Chronic Liver Failure. 136 scientists from 47 centers and institutions in 14 European countries are involved in PREDICT.
Publikation: Jonel Trebicka, Javier Fernandez, Maria Papp, Paolo Caraceni, Wim Laleman, Carmine Gambino, et al.: The PREDICT study uncovers three clinical courses of acutely decompensated cirrhosis that have distinct pathophysiology. Journal of Hepatology, https://doi.org/10.1016/j.jhep.2020.06.013