Thread by @JHaydek

Last week I asked about confusing #GI topics for internists, and the consensus was that acute on chronic liver failure (#AoCLF) has been causing ample confusion (🤞 not from NH3). Plus, I've been consulted every week for AoCLF, despite none actually having it. So, a 🧵

1/10

So, what IS AoCLF? Same thing as acute liver failure (#ALF), right?

NO! 🤷‍♂️

There's no clear consensus, but generally you need to have:

▶️Decompensated cirrhosis
▶️Acute change 2/2 sudden inflammatory state (infection, acute hepatitis, etc)
▶️End organ damage

2/10

Plus, there must be a relationship b/w the instigating event & worsening liver disease. Can't blame the UTI from 2w ago.

👉The most common etiology of AoCLF is bacterial infection, and so start by looking there (and don't forget occult SBP!)

jwatch.org/na50598/2020/0…

3/10

On top of all of that, there are physiologic compensatory changes that occur in chronic liver disease, which is why it's important to differentiate the two from eachother.

See 👇@DebbieShawcros1's paper to read more about ammonia metabolism changes ncbi.nlm.nih.gov/pmc/articles/P…

4/10

...and, as an aside, if you haven't read @ebtapper's 🧵on hepatic encephalopathy and "meat stupor," now's your chance to have your mind blown.

https://twitter.com/ebtapper/status/1018666720679034880?s=20

5/10

So, to summarize so far:
🔸AoCLF is a worsening of decompensated cirrhosis w/ new end organ damage due to an inciting event (often bacterial infection)

and

🔸AoCLF is NOT ALF

6/10

In addition to different pathophysiologies, the outcomes between the two are much different.

🔸30-day mortality of ALF is around 26%, while for AoCLF, it's around 40%, almost twice as high (although this number also depends on amount of organs failing, and up to 97%❗️)

7/10

Lastly, what should you do about AoCLF? Unfortunately there's no magic pill:

▶️Treat underlying inciting event, as best as possible
▶️Supportively manage end organ damage, as best as possible
▶️Consider liver transplant, if all else fails.

8/10

So to summarize:
1⃣ AoCLF ≠ ALF
2⃣ AoCLF is an acute worsening of hepatic function in someone who already has evidence of cirrhosis
3⃣ Most common cause is bacterial infection (don't forget about occult SBP)
4⃣ Outcomes are worse for AoCLF than ALF
5⃣ Treat supportively

9/10

Thanks everyone for reading along, to @EricLawson90 for the inspiration, and to @_amolk & @EmmGeezee for the topic idea. References h/t to Sleisenger, and @RajivJalan1's recent @NEJM paper from May, among others.