Cirrhosis and Liver Failure
Systemic inflammation is associated with increased intrahepatic resistance and mortality in alcohol-related acute-on-chronic liver failure
Article first published online: 23 APR 2014
© 2014 John Wiley & Sons A/S. Published by John Wiley & Sons Ltd
Volume 35, Issue 3, pages 724–734, March 2015
How to Cite
Liver Int. 2015; 35: 724–734
- Issue published online: 11 FEB 2015
- Article first published online: 23 APR 2014
- Accepted manuscript online: 4 APR 2014 07:26AM EST
- Manuscript Accepted: 28 MAR 2014
- Manuscript Received: 21 JAN 2014
- hepatic circulation;
- hepatic haemodynamics;
- portal hypertension
Background & Aims
Acute-on-chronic liver failure (ACLF) is characterized by acute deterioration of cirrhosis, systemic inflammation and multi-organ failure. Inflammation is also key to the pathobiology of portal hypertension. This study aims to define the relationship between systemic and hepatic haemodynamics in patients with ACLF.
Sixty patients with alcoholic cirrhosis were prospectively enrolled – stable cirrhosis (SC, n = 27), acute decompensation without ACLF (AD, n = 14) and ACLF (n = 19) – and managed with standard therapy. Systemic and hepatic haemodynamic studies were performed, and patients were followed up for 3 months. Plasma norepinephrine, cytokine profile, nitrate/nitrite and malondialdehyde levels were measured.
Three-month mortality was as follows: SC – none; AD – 14%; ACLF – 47.2% (P < 0.001). Mean arterial pressure was lowest in the ACLF group (P < 0.001). ACLF patients had significantly higher hepatic vein pressure gradient (HVPG), while the hepatic blood flow was markedly reduced with an increase in intrahepatic resistance, which predicted mortality (AUROC: 0.87, P < 0.0001). In ACLF, the severity of intrahepatic resistance correlated with markers of inflammatory response, norepinephrine levels, creatinine levels and severity of encephalopathy. Modelling data showed that the high norepinephrine levels in ACLF may contribute to the right shift of the HVPG–hepatic blood flow relationship and its levels correlated with inflammatory markers and mortality (AUROC: 0.90; P < 0.0001).
The disturbances in systemic and hepatic haemodynamics in alcohol-related ACLF are associated with dysregulated inflammation, multi-organ failure and marked activation of the sympathetic nervous system. These abnormalities predict high mortality rates in alcohol-related ACLF patients.