Decompensation Of Chronic Liver Disease Research Articles

Early prediction of acute-on-chronic liver failure development in patients with diverse chronic liver diseases

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by the acute decompensation of chronic liver disease, resulting in organ failure and high short-term mortality. The progression of ACLF is dynamic and reversible in a considerable proportion of patients during hospitalization. Early detection and accurate assessment of ACLF are essential; however, ideal methods for this purpose are still lacking. Therefore, this study aimed to develop a new score for predicting the onset of ACLF in patients with various chronic liver diseases.A total of 6,188 patients with various chronic liver diseases were included in the study. Clinical and laboratory data were collected, and the occurrence of ACLF within 28 days was recorded. The Lasso-Cox regression method was employed to develop prediction models for the onset of ACLF at 7, 14, and 28 days. Among 5,221 patients without ACLF, 477 progressed to ACLF within 28 days. Seven predictors were identified as significantly associated with the occurrence of ACLF at 7, 14, and 28 days. A new scoring system was developed as follows: [NEUT ≥ 7, 109/L; 1 or 0] × 0.49 + [PLT < 100, 109/L; 1 or 0] × 0.44 + [TBIL ≥ 35, µmol/L; 1 or 0] × 0.05 + [HDL-C < 0.5, mmol/L; 1 or 0] × 1.04 – Ln[Hb, g/L] × 0.89 + [BUN > 7, mmol/L; 1 or 0] × 0.51 + Ln[INR] × 0.87 + 3.40. This new score demonstrated superior discrimination, with the C-indexes of 0.958, 0.944, and 0.938 at 7, 14, and 28 days, respectively, outperforming those of four other scores (CLIF-C-ACLF-Ds, MELD, MELD-Na, and CLIF-C-ADs score; all P < 0.001). Additionally, the new score improved in predictive accuracy, time-dependent receiver operating characteristics, probability density function evaluations, and calibration curves, making it highly predictive for the onset of ACLF at all time points. The optimal cut-off value of 9.6 effectively distinguished between high- and low-risk patients for ACLF onset. These findings were further validated in a separate cohort of patients. A new progressive score, based on seven predictors, has been developed to accurately forecast the occurrence of ACLF within 7, 14, and 28 days in patients with various chronic liver diseases. This tool may be utilized to identify high-risk patients, tailor follow-up management, and guide the escalation of care, prognostication, and transplant evaluation.

A Study On Haematological Abnormalities In Decompensated Chronic Liver Disease At Government General Hospital, Vijayawada

Background: chronic liver failure is usually associated with hypersplenism and diminished erythrocyte survival is frequent. Dietary deficiencies, alcoholism, bleeding and defective hepatic synthesis of proteins used in blood formation or coagulation worsen the problem. Plasma volume is increased in patients with cirrhosis,particularly in those with ascites ,this hypervolemia may account for a low peripheral hemoglobin or erythrocyte level. Materials and methods: this is a crosssectional,analytical study of 100 patients conducted in patients with decompensated chronic liver disease admitted in siddhartha medical college hospital during the period january 2023 to december 2023. Results: our study included 100 patients with decompensated chronic liver disease,upon performing haematological profile ,anemia is seen in 88%,thrombocytopenia is seen in 80%,elevated pt,inr in 37% patients which predict the chances of upper gi bleed.derangements in these parameters can ultimately lead to grave complications

Hyponatremia Prevalence in Decompensated Chronic Liver Disease: Insights from a Tertiary Care Hospital.

Liver cirrhosis is a prominent global contributor to mortality, and hyponatremia is a common complication in patients with decompensated chronic liver disease (DCLD). Hyponatremia is characterized by kidney impairment when eliminating solute-free water. The presence of contradictory findings in existing literature prompted this study. The objective of this study was to determine the prevalence of hyponatremia in patients with DCLDs presenting at a tertiary care hospital. This six-month cross-sectional study was performed at the Allied Institute of Medical Sciences Teaching Hospital in Gujranwala, Pakistan, from January 2022 to June 2022. A total of 133 patients were selected as subjects. Researchers took blood samples from these patients and sent the samples to the hospital pathology lab for evaluation of serum sodium levels. If sodium levels were ≤130 mmol/L, the patient was considered to have hyponatremia. All information was recorded on proforma. The mean age of patients was 47.68 ± 12.89 years. Overall, 80 (60.15%) were male, and 53 (39.85%) female. The mean BMI of patients was 23.20 ± 3.11 kg/m2 and the average duration of DCLD was 7.24 ± 4.12 years. Among participants, 48 (36.09%) patients had hyponatremia, whereas 85 (63.91%) did not have hyponatremia. The mean sodium level was 132.39 ± 11.37 mEq/L. Stratified analysis based on patient age revealed that among patients aged 21-45 years, 27 (45.8%) had hyponatremia, whereas, in the group aged 46-70 years, 21 (28.4%) had hyponatremia with a p-value < 0.05. Stratification of the basis of BMI, among underweight patients, all eight (100%) had hyponatremia, whereas of overweight patients, 14 (31.1%) had hyponatremia. This difference was statistically significant (p < 0.05). The prevalence of hyponatremia was notably elevated among individuals suffering from DCLD. Age and BMI were the most common risk factors for hyponatremia among subjects with DCLD. This study recommends that patients with DCLD should have their serum sodium levels screened at regular intervals to prevent complications, including encephalopathy, which occurs particularly in younger and underweight DCLD patients.

Biomarker for infection in children with decompensated chronic liver disease: Neutrophilic CD64 or procalcitonin?

ObjectiveBiomarkers with high accuracy for identification of infection in decompensated chronic liver disease (DCLD) are urgently needed. We compared the accuracy of neutrophilic cluster of differentiation 64 (nCD64) with procalcitonin for diagnosis of bacterial infection in children with DCLD. MethodsConsecutive children admitted with DCLD were enrolled prospectively. nCD64 was assessed by flow cytometry and expressed in percentage. nCD64, procalcitonin and hemogram were measured at admission and 7-14 days after treatment in those with infection. Complete work-up for infection was done. Presence, site and severity of infection was classified as per guidelines. Results107 children [64 boys, age 97(18-168) months] were enrolled. 78(72.9%) had infection, 26(24%) had severe sepsis and 60(56%) had systemic inflammatory response syndrome. The commonest site of infection was ascitic fluid (n=37), followed by pneumonia (n=24), urinary tract (n=15), bacteraemia (n=10), cholangitis (n=8) and cellulitis (n=3). nCD64 (cut-off-51%, AUC-0.82) had a higher sensitivity (79.5%) and specificity (82.8%) than procalcitonin (cut-off ≥0.58ng/mL, AUC-0.74, sensitivity-76.9% and specificity-62.1%) for diagnosis of infection. nCD64 and procalcitonin correlated with infection severity, being highest in children with severe sepsis [88(71-97) %and 1.98(0.83-10.36) ng/mL], than in infection alone [72(45-84) % and 1.09(0.45-2.07) ng/mL], and no-infection [36(20.2-48) % and 0.42(0.19-1.08) ng/mL]. There was no difference in diagnostic utility of procalcitonin or nCD64 with different sites of infection. Elevation of all 3 parameters (nCD64, PCT and total leukocyte count) was uncommon but highly specific for presence of infection. ConclusionnCD64 identifies infection better than procalcitonin and correlates well with infection severity in children with DCLD.

Correlation of Portal Hypertensive Gastropathy with the Size of Esophageal Varices in Patients with Decompensated Chronic Liver Disease:

Objectives: To determine the correlation of portal hypertensive gastropathy with esophageal variceal size. To determine the differences in gender of esophageal varices Study design: A cross-sectional study was done from January 2022- October 2022 on 440 patients reporting to JPMC, Karachi having portal hypertensive gastropathy and were assessed for severity of esophageal varices based on endoscopic findings. Methodology: The new Italian Endoscopic Club criterion was used for portal hypertensive gastropathy (PHG) and the Japanese Research Society for Portal Hypertensive Gastropathy to describe the grading of esophageal varices. Results: Of 440 patients 163 (37%) were female and 277 (63%) were males. The size of esophageal varices correlated with severity and a Spearman p&lt;0.1% was seen which is significant. Male patients showed a significantly higher chance of having larger-sized varices. Conclusions: The size of varices correlates to severe decompensated chronic liver diseases (DCLD). Hence, patients with advanced liver cirrhosis are likely to be at risk of severe upper GI bleeds

Evaluating Diastolic Dysfunction as an Indicator of Cirrhotic Cardiomyopathy in Decompensated Chronic Liver Disease.

The clinical syndrome of cirrhotic cardiomyopathy (CCM) occurs quite frequently in decompensated chronic liver disease (DCLD) patients without any prior incidence. The compromised life expectancy under such conditions was the key that prompted us to conduct this study. This study was planned to study the prevalence of diastolic dysfunction in chronic liver disease patients, to understand the diagnostic criteria of left ventricular diastolic dysfunction(LVDD) in cirrhotic patients, and to evaluate its occurrence as an early indicator of CCM. A hospital-based, cross-sectional study was conducted on 158 patients, admitted to the Department of Medicine, Rajendra Institute of Medical Sciences, Ranchi, India, who conformed to our criteria for inclusion and exclusion.The study period was for 18 months. The subjects were clinically and radiologically diagnosed with chronic liver disease. Regression analysis for variables was performed to score the effects of potential variables with outcomes for diastolic dysfunction (DD) prediction. Out of 158 patients, 116 belonged to the age group of 31-60 years, pronouncing age to be a significant factor for LVDD. Fifty-threesubjects had serum bilirubin levels >2mg/dL and we found serum bilirubin levels to bear a significant correlation with LVDD by exhibiting a p-value <0.0001. Both the Child-Turcotte-Pugh score class (p-value=0.0180) and QTc (p-value <0.0001) bear significant correlation with the development of LVDD, which is also evident from their area under the curve (AUC) values of 0.64 in the receiver operating characteristic (ROC) curve. Our study concludes that LVDD is an early indicator for assessing the severity of liver cirrhosis in DCLD. The correlation of DCLD with prolonged QTc could predispose patients with DCLD to ventricular arrhythmias. Hence, such patients should undergo serum bilirubin tests, and electrocardiographic checks at regular intervals for early detection, to increase their overall survival rates.

Technical Challenges in Simultaneous Living Donor Liver Transplantation and Domino Orthotopic Liver Transplantation

Liver transplantation is the ideal treatment of choice for Familial amyloid polyneuropathy (FAP). It is known that during transplantation surgery, this explant liver which will be removed from amyloid patient can be used as a domino graft for another suitable recipient. Even after successful results of domino liver transplantation in deceased donation setting this procedure is always seen with a fear of putting both the recipients at risk due to technical challenge. With living donor as the liver donor for the amyloid patient, the challenges faced are even higher. Only few centres have done similar surgeries and there are no standard guidelines for the same. The anatomical prerequisites, technique, and indications of domino orthotopic liver transplant (D-OLT) in live donation settling are still evolving. We here report a case of live donor liver transplant from a 38 year old with a Right lobe graft for a 40 year old with FAP along with D-OLT for a 52 year old with HBV related decompensated chronic liver disease with HCC. We have described the technical challenges and learnings in our first case which is one of few cases done in the Indian Subcontinent.

Comparison of Rifaximin Alone and With Quinolones in the Primary Prevention of Spontaneous Bacterial Peritonitis in Patients With Decompensated Chronic Liver Disease.

Background In cirrhotic patients with ascites, primary prevention of spontaneous bacterial peritonitis (SBP) is a key strategy to lower morbidity and death. Rifaximin and fluoroquinolone used alternately as main prophylaxis are as effective as reported. This study aimed to compare the frequency of occurrence of SBP in patients with decompensated chronic liver disease treated with rifaximin alone and in combination with fluoroquinolone. Methodology A total of 76 patients with hepatitis C virus-related decompensated chronic liver disease and ascites were divided into two groups based on matching age, sex, and Child-Pugh class. Group A (38 patients) received rifaximin 1,100 mg/day in two divided doses with daily fluoroquinolone 400 mg/day, whereas group B (38 patients) received rifaximin 1,100 mg/day alone as a two dosage. The patients were monitored for up to three months. The study's endpoints were SBP, hepatocellular carcinoma, compliance failure, death, or liver transplantation. Results In this comparative study involving 76 patients, the demographic and clinical characteristics were assessed across two treatment groups: rifaximin alone (n = 38) and rifaximin with fluoroquinolone (n = 38). The combination therapy demonstrated a statistically significant reduction in SBP compared to rifaximin alone. Additionally, the overall survival rate was higher in the combination group. These findings suggest potential benefits of the combined approach in managing hepatic encephalopathy-related complications. Conclusions When compared to rifaximin alone for primary SBP prophylaxis, the combination of rifaximin with fluoroquinolone exhibited greater effectiveness with the same safety profile.

Sexual Dimorphism in Decompensated Non Ethanol-related Chronic Liver Disease: A Retrospective Cohort Study

Introduction: Women exhibit a distinct natural history of chronic liver disease compared to men, particularly regarding progression and outcomes. Although liver disease prevalence is generally higher in men, the incidence of non ethanol-related liver disease is increasing among females. Metabolic syndromes and their consequences are less recognised in the female population until they develop end-stage cirrhosis. Limited studies have explored the differences between male and female cirrhosis. The present study aimed to address the knowledge gap in female Decompensated Chronic Liver Disease (DCLD). Aim: To identify the differences in presentation and outcomes between females and males with non ethanol-related cirrhosis. Materials and Methods: The present retrospective cohort study was conducted in the Department of Medical Gastroenterology and Hepatology,Tirunelveli Medical College, Tirunelveli, Tamil Nadu, India, involving 27 males and 33 females with non ethanol-related decompensated cirrhosis. A comparison was made between the aetiologies, presenting symptoms, complications, laboratory values, Model for End-stage Liver Disease (MELD) score, and in-hospital mortality during the first decompensation. Data analysis was performed using Statistical Packages for Social Sciences (SPSS) version 24.0 Quantitative variables were expressed as mean and Standard Deviation, while qualitative variables were expressed as frequency and percentage. The association between categorical variables was analysed using the Chi-square test, and the comparison of continuous variables between the two groups was analysed using independent sample t-test. A p-value of &lt;0.05 was considered statistically significant. Results: The mean age of decompensation was 56.5 years for men and 50.9 years for women. The most common aetiology in men was Non Alcoholic Fatty Liver Disease (NAFLD) (63%), while in females, it was NAFLD (45%) and cryptogenic cirrhosis (45%) (p=0.020). Diabetes Mellitus (DM) was more prevalent in males (55.6% versus 33.3%). Variceal bleed was more common in females (66.7% versus 48.1%). Jaundice was more frequently observed in males (44.4% versus 21.2%) (p=0.05). Ascites was more prominent in males (70.4% versus 45.5%) (p=0.05). Hepatic Encephalopathy (HE) was more prevalent in males (22.2% versus 15.2%). Females had a lower MELD scores compared to males (12.4±6.1 versus 15.2±6.4). Mortality was higher in males (22.2% versus 12.1%). Conclusion: Women with Decompensated Chronic Liver Disease tend to decompensate at a younger age compared to males and have a higher risk of Upper Gastrointestinal (UGI) bleeding. NAFLD was the most common aetiology in both groups. Ascites and HE were more commonly observed in men. Females had lower MELD scores, resulting in a longer waiting period on the transplant list compared to males. Mortality was higher in males.

Hypocoagulability in Children With Decompensated Chronic Liver Disease and Sepsis: Assessment by Thromboelastography.

To evaluate the coagulation status of children with decompensated chronic liver disease (DCLD) and infection and factors affecting it using thromboelastography (TEG). Coagulation status of children admitted with DCLD and infection was assessed by international normalized ratio (INR), platelet count, and TEG [reaction time (R), kinetic time (K), α-angle (AA), maximum amplitude (MA), coagulation index (CI), and lysis index (LY30)] at admission and at 7-14 days after treatment. CI < -3 represents hypocoagulable state. Clinical profile including systemic inflammatory response syndrome (SIRS), infection severity, bleeding, treatment response, and outcome were noted. Thirty children (21 boys, median (IQR) age 78 [15.7-180] months) were studied prospectively. At admission, 29 (96.7%) had prolonged INR, 24 (80%) had thrombocytopenia, and 17 (56.6%) were hypocoagulable by TEG. Nine of 30 (30%) had normal TEG but deranged INR and platelets. Nineteen (63.3%) cases had SIRS, 11 (36.6%) had severe sepsis, and 8 (26.6%) had bleeding. Hypocoagulable state was common in severe sepsis than sepsis/infection (81.1% versus 42.1%; P = 0.05) and persistent (n = 4) versus recovered SIRS (n = 15, 100% versus 33%; P = 0.03). Bleeders had prolonged R-time (7.8 versus 5.4 min; P = 0.03), smaller MA (30.2 versus 47 mm; P = 0.05), and α-angle (40.4 versus 62.9; P = 0.03) but similar INR and platelets than nonbleeders. Six patients (20%) had poor in-hospital outcomes; R-time ≥8.5 min predicted mortality with high sensitivity (83%) and specificity (100%). Fifth-seven percent of children with DCLD and infection were hypocoagulable by TEG. Severe sepsis and persistent SIRS worsened the coagulation status. TEG identifies bleeders better than INR and platelet count. R-time ≥8.5 min predicts a poor hospital outcome.

Challenges in Diagnosis and Therapeutic Approach of Acute on Chronic Liver Failure-A Review of Current Evidence.

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute and severe decompensation of chronic liver disease (CLD) correlated with multiple organ failure, poor prognosis, and increased mortality. In 40-50% of ACLF cases, the trigger is not recognized; for many of these patients, bacterial translocation associated with systemic inflammation is thought to be the determining factor; in the other 50% of patients, sepsis, alcohol consumption, and reactivation of chronic viral hepatitis are the most frequently described trigger factors. Other conditions considered precipitating factors are less common, including acute alcoholic hepatitis, major surgery, TIPS insertion, or inadequate paracentesis without albumin substitution. Host response is likely the primary factor predicting ACLF severity and prognosis, the host immune response having a particular significance in this syndrome, together with the inflammatory cascade. The management of ACLF includes both the prevention of the precipitating factors that lead to acute liver decompensation and the support of vital functions, the prevention and management of complications, the estimation of prognosis, and the opportunity for liver transplantation.

Hepatic Encephalopathy Confirmed by Magnetic Resonance Imaging in a Patient with Unobvious Cause of Chronic Liver Disease Decompensation

Fifty-four-year old male was admitted to the intensive care unit (ICU) due to impaired consciousness. Past medical history included alcohol dependence, liver cirrhosis, esophageal varices, 2 esophageal varices banding procedures in the past, pathological obesity. Computed tomography (CT) examination of the head performed in the referring hospital was normal. At admission the CT examination of the head was repeated and showed no abnormalities. Urgent esophagogastroduodenoscopy revealed presence of esophageal varices and scarification following previous banding procedures located in the middle and lower part of the esophagus. Gastrointestinal bleeding being the most likely cause of chronic liver decompensation was therefore excluded. Multimodal neurologic diagnostic assessment was negative. Finally magnetic resonance imaging (MRI) of the head was performed. Taking into account clinical picture and the MRI result, the differential diagnosis included chronic liver encephalopathy, exacerbated acquired hepatocerebral degeneration, and acute liver encephalopathy. Due to history of umbilical hernia CT of the abdomen and pelvis was performed and showed intussusception of the ileum, confirming hepatic encephalopathy. In this case report the MRI suggested the diagnosis of hepatic encephalopathy and prompted search for alternative causes of decompensation of chronic liver disease.

Urine neutrophil gelatinase-associated lipocalin as a biomarker of acute kidney injury and prognosis in decompensated chronic liver disease: A prospective study.

Acute kidney injury (AKI) heralds deterioration in patients with decompensated chronic liver disease (DCLD). Serum creatinine (sCr), a component of the model for end-stage liver disease-sodium (MELD-Na) prognostic score, has limitations in patients with DCLD. We evaluated the prognostic role of urine neutrophil gelatinase-associated lipocalin (NGAL) in DCLD and its ability to sub-type AKI. Total 147consecutive patients hospitalized between June 2018 andJune 2020 for complications of DCLD were evaluated. Urine NGAL was estimated and demographic, clinical and biochemical parameters recorded at baseline. Participants were followed up till theend of study period or mortality, whichever came earlier. Primary outcomes included all-cause mortality and time to death after index hospitalization. Secondary outcomes included thepresence and type of AKI, need for intensive care unit (ICU) stay, length of ICU/hospital stay, in-hospital mortality, development of new-onset/recurrent AKI and recurrent hospitalization after index admission. Urine NGAL was highest in acute tubular necrosis (ATN), lowest in pre-renal azotemia (PRA) and intermediate in hepatorenal syndrome (HRS-AKI). Urine NGAL (p = 0.0208) was superior to sCr (p = 0.0388) and inferior to fractionated excretion of sodium (FENa) (p = 0.0013) in stratifying AKI. A cut-off of 203.9ng/mL discriminated between HRS and PRA with sensitivity 77.8% and specificity 68.7%. Urine NGAL correlated with MELD-Na score, need for ICU stay, in-hospital mortality and mortality at three and sixmonths. Two-year survival was significantly lower in patients with urine NGAL > 205ng/mL. Addition of log-urine-NGAL score did not improve predictive performance of MELD-Na. Urine NGAL could identify AKI sub-types and correlated with short-term clinical outcomes, including mortality.

Hepatogenous Diabetes; an Overlooked Entity and its Implications in Course Of Decompensated Chronic Liver Disease: An Interim Analysis

Hepatogenous Diabetes; an Overlooked Entity and its Implications in Course Of Decompensated Chronic Liver Disease: An Interim Analysis

Assessment of Serum Biochemical Changes in Hepatic Encephalopathy

Objective: To analyze the association of various biochemical changes with different grades of hepatic encephalopathy among patients of hepatitis C-related decompensated liver disease presenting at Pak Emirates Military Hospital. Rawalpindi, Pakistan.&#x0D; Study Design: Comparative cross-sectional study.&#x0D; Place and Duration of Study: Medicine and Gastroenterology Department of Pak Emirates Military Hospital (PEMH), Rawalpindi Pakistan, from Mar 2020 to Feb 2021.&#x0D; Methodology: This study was conducted on 100 patients with hepatitis C-related decompensated liver. A consultant medical specialist or gastroenterologist graded hepatic encephalopathy according to the West Haven criteria. Serum urea, creatinine, albumin and international normalized ratio were performed in all the patients at the time of grading of encephalopathy and derangement in the level of these parameters was analyzed with Grades of encephalopathy.&#x0D; Results: Out of 100 patients, in the final analysis, 66 were males, and 44 were females. The commonest aetiology of hepatic encephalopathy was Infection (33%) followed by Constipation (29%). 15 patients had Grade-1 encephalopathy, 43 had Grade-2, 26 had Grade-3 while 16 had Grade-4 encephalopathy. Deranged serum creatinine, international normalized ratio and albumin levels were significantly associated with a higher grade of hepatic encephalopathy (p-value&lt;0.05) in our study participants.&#x0D; Conclusion: Biochemical markers studied in patients with hepatic encephalopathy secondary to hepatitis C-related decompensated chronic liver disease were deranged. In addition, creatinine, albumin and International normalized ratio were found to be more deranged in higher grades of encephalopathy.

S1190 Therapeutic Effect of Granulocyte Colony-Stimulating Factor Therapy for Acute-on-Chronic Liver Failure: A Meta-Analysis of Randomized Controlled Trials

Introduction: Acute-on-chronic liver failure (ACLF) is a condition characterized by acute decompensation of chronic liver disease, accompanied by the failure of one or more extra-hepatic organs and high short-term mortality. Currently, liver transplantation is the only definitive treatment for ACLF but it is not beneficial to all patients due to limited donors, expensive procedure and high risk of adverse effects, so granulocyte stimulating factor (G-CSF) is considered as an alternative treatment. However, its therapeutic effectiveness is still debaTable, so we aimed to conduct a meta-analysis to evaluate the clinical efficacy of G-CSF In patients with ACLF. Methods: MEDLINE and SCOPUS were queried from inception till June 2022 for randomized controlled trials (RCTs), without any restriction. RCTs evaluating effects of G-CSF on survival rates and occurrence of infection in patients with ACLF were incorporated. The results were reported using a random-effects meta-analysis and the Mantel-Haenszel risk ratio (RR).The Subgroup analysis was done to investigate the influence of study-level factors such as study setting, population and etiology on the outcomes of interest. Results: Thirteen studies (n = 13) were included in our meta-analysis. The total number of participants in our study was 913, and the median study duration was 3 months. Our pooled analysis demonstrates that G-CSF therapy significantly improved survival rates (RR 1.52; 95% CI 1.23 to 1.88; p = 0.0001; Figure) in patients with ACLD. In our subgroup analysis, G-CSF was found to be associated with an improved survival rate in patients with viral hepatitis (RR 1.47; 95% CI 1.27 to 1.69; p < 0.00001). In contrast, results for patients with alcoholic hepatitis were insignificant (RR 1.66; 95% CI 0.88 to 3.16; p< 0.12). Pooled analysis also showed that G-CSF therapy significantly reduces the occurrence rate of infection more than SMT (RR 0.58; 95% CI 0.39 to 0.86; p= 0.006). In the subgroup analysis for viral hepatitis patients, G-CSF therapy was also significantly beneficial in reducing the occurrence rate of infection (RR 0.56; 95% CI 0.35 to 0.89; p=0.01), but in patients with alcoholic hepatitis, results were insignificant (RR 0.55; 95% CI 0.31 to 0.99; p=0.05). Conclusion: Our findings indicate that G-CSF therapy is beneficial in improving survival rates and reducing the risk of infection in patients with ACLF. Hence, it can be used as an alternative treatment for patients with ACLF.Figure 1.: Survival rates in patients with alcoholic hepatitis and viral hepatitis

Paediatric Acute-on-Chronic Liver Failure: A Review of Current Evidence in Children

Acute-on-chronic liver failure (ACLF) is a syndrome that describes acute decompensation of chronic liver disease with differing definitions worldwide, but is universally associated with high short-term mortality. This is becoming increasingly recognised as a unique entity that affects both adults and children. This narrative review summarises the current available evidence from paediatric studies on definition, incidence, pathophysiology, and outcome, with reference to data on ACLF from adult literature. Paediatric data remain scarce, and study groups have used differing inclusion criteria that have limited generalisability of data. There is a crucial need for a consensus definition for paediatric ACLF so that future collaborative research may provide better understanding on the epidemiology, pathophysiology, risk factors, and outcome of this clinical entity.

Non-hepatotropic viral hepatitis and its causative pathogens: The ongoing need for monitoring in children with severe acute hepatitis of unknown etiology.

Non-hepatotropic viral hepatitis and its causative pathogens: The ongoing need for monitoring in children with severe acute hepatitis of unknown etiology.

The Burden of Gastrointestinal, Hepatobiliary and Pancreas Related Diseases and Their Causes at Tertiary Care Hospital in Karachi

Objective: To determine the burden of gastrointestinal, hepatobiliary and pancreas-related disease, frequencies and their presentations.&#x0D; Study Design: Cross-sectional study.&#x0D; Place and Duration of Study: Gastroenterology Department, Liaquat National Hospital, Karachi from Oct 2020 to Jul 2021&#x0D; Methodology: Patients aged ≥18 years, having diagnosis related to gastrointestinal, hepatobiliary and pancreas were included in the study. Demographic features, reasons for admission, and length of stay were recorded.&#x0D; Results: A total of 2183 patients were enrolled. Nearly half of the patients were ≥60 years. 43% of patients were presented with abdominal pain. The most frequent diagnosis includes decompensated chronic liver disease followed by upper gastrointestinal bleed. The proportion of female patients was significantly higher for gastritis (p=0.009) and acute cholecystitis (p=0.036), while males with Hepatitis-B (p=0.019) and liver abscesses (p=0.018) were significant. Admissions through emergency were higher for gastrointestinal bleeding and decompensated chronic liver disease (p&lt;0.001) in monitoring setup (p=0.034), ward admission via OPD were significant for upper gastrointestinal malignancy (p=0.011) and hepatocellular carcinoma (p=0.038). Extended length of stay and expiry was significant among acute liver failure (p=0.047) and gastric outlet obstruction (p=0.030).&#x0D; Conclusion: Notably, highly evitable diseases are still a foremost reason of clinical importance, lack of awareness and low cure rate, especially in rural areas progress to high fatality as most patients do not seek medical assistance until significant manifestation. This appeals to more effective measures, including eradicating the potentially life-threatening disease.

Triggers for de-compensation of Chronic Liver Disease in South of Lahore

Background: Cirrhosis is a leading cause of mortality and morbidity across the world with cases number estimated to be as high as 1.5 Billion. Pakistan is one of the countries where the burden of disease is significantly high. Aim: To understand potential causative factors contributing towards decompensation of liver disease and report it for the benefit of other units providing service to similar population. Study design: Prospective observational study Methods: Common complications of portal hypertension resulting from chronic liver disease include development of ascites, encephalopathy, GI bleeding and hepato-renal syndrome. Decompensation of cirrhosis can be transient with full recovery (re-compensation), or it can be chronic. During an event of acute decompensation, clinicians strive to treat the underlying trigger which may have resulted in decompensation alongside the supportive treatment. Several of such potential factors have been reported in the literature. New infection, dehydration, consumption of alcohol and new medications are a few to mention. Many a times the cause of decompensation remains unclear. Results: The patients with established cirrhosis can develop such complications of the disease resulting in what is known as decompensation at any point during disease. It is imperative for a liver unit to know the relevant causes of hepatic decompensation in its own patients so that the treatment is based on the evidence from local population; the data which is scarce. Conclusion: Non-compliance with medical advice was the commonest factor as opposed to the available data most of which reports infection as the commonest factor, although infection was the second most common factor, and the commonest concomitant factor in this subset of patients. Cause of decompensation remains unidentified in over one fourth of cases. Keywords: Decompensation, trigger, chronic liver disease