Acute-on-Chronic Liver Failure (ACLF): The ‘Kyoto Consensus’-Steps From Asia

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the APASL ACLF Research Consortium (AARC) was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia-Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the \u27Golden Therapeutic Window\u27, the \u27transplant window\u27, and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The \u27Kyoto APASL Consensus\u27 presented below carries the final recommendations along with the relevant background information and areas requiring future studies

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Low Eosinophil Count : A Predictor of Inhospital Mortality in a Cohort of Cirrhosis Patients With Sepsis

Abstract Background and Aims:Eosinopenia has recently been associated with sepsis. Thus, eosinopenia can be used as a marker of the severity of sepsis and high mortality, which helps in early identification of high risk patients, so better management can be offered to such patients. Aim of the study was to assess whether Absolute Esoinophil Count (AEC) at the time of ICU admission can be used as a predictor of inhospital mortality in cirrhotics.Materials and Methods:This study was a retrospective cohort study. The study population included cirrhosis patients admitted in ICU and High Dependency Unit with sepsis and their absolute eosinophil counts were assessed on the day of hospital admission.Results: A total of 105 patients were enrolled in the study. Among the various parameters analyzed, MELD score, CTP score, Albumin levels, Total count, CRP, ESR, ALT, Bilirubin, Creatinine, Urea, SIRS and Absolute Eosinophil Count(AEC) were statistically significant in predicting the mortality. AUROC of AEC for predicting mortality was 0.881. Cutoff of AEC by Youden’s index was 110 cells/cumm (sensitivity 91.3%, specificity 89%, positive predictive value 87.5% and negative predictive value 93%) in predicting inhospital mortality. MELD AUROC was 0.78 with cut off of &gt; 24 (sensitivity 89%, specificity 74.6%, positive predictive value 73% and negative predictive value 89%) to predict mortality. Conclusion:In critically ill cirrhosis patients, absolute eosinophil count less than 110 cells/cumm can predict inhospital mortality.</jats:p

Eosinophil count: a predictor of in-hospital mortality in a cohort of cirrhosis patients with sepsis

Abstract Background Declining eosinophil count has recently been associated with sepsis. Thus, absolute eosinophil count (AEC) can be used as a marker of the severity of sepsis, which helps in the early identification of high-risk patients, and better management can be offered to such patients. The aim of this study was to assess whether AEC at the time of ICU admission can be used as a predictor of in-hospital mortality in cirrhotics with sepsis. Results This was a retrospective study which was conducted in 105 cirrhotic patients admitted with sepsis in the Department of Gastroenterology, Medical College Trivandrum, from May 2014 to October 2014. Every consecutive patient with cirrhosis and sepsis (defined as systemic inflammatory response syndrome (SIRS) and the presence of infections) admitted to the ICU/high dependency unit was recruited for the study. Among the various parameters analyzed, model for end-stage liver disease (MELD) score, Child-Pugh Turcot (CTP) score, albumin levels, total count, C-reactive protein (CRP), erythrocyte sedimentation rate (ESR), alanine aminotransferase (ALT), bilirubin, creatinine, urea, and absolute eosinophil count were statistically significant in predicting in-hospital mortality. The AUROC of AEC was plotted and found to be 0.881, which was better than other parameters for predicting in-hospital mortality. The cutoff of AEC by Youden’s index was 110 cells/cumm (sensitivity 91.3%, specificity 89%, positive predictive value 87.5%, and negative predictive value 93%) to predict in-hospital mortality. The AUROC of MELD was 0.78 with a cutoff of &gt; 24 (sensitivity 89%, specificity 74.6%, positive predictive value 73%, and negative predictive value 89%) to predict the mortality. The odds ratio for predicting mortality was highest for absolute eosinophil count (92.75) followed by MELD (24.57), total count (20.475), CTP (10), and the presence of SIRS (9.08). Conclusion In critically ill cirrhosis patients with sepsis, AEC &lt; 110 cells/cumm can predict in-hospital mortality. </jats:sec

Metastatic <i>Crohn&#x2032;s disease</i> of external genitalia

Metastatic Crohn&#x2032;s disease is an uncommon extraintestinal manifestation of Crohn&#x2032;s disease. Its hallmark features include the presence of cutaneous noncaseating granulomas that are noncontiguous with the gastrointestinal tract or fistula. We report a rare case of metastatic Crohn&#x2032;s disease involving the external genitalia in a 14-year-old girl. Diagnosis was based on skin biopsy. Patient had complete recovery on treatment with oral and topical steroids along with azathioprine

CRAB score for prediction of colectomy within 2 years following admission for acute severe ulcerative colitis

Background: The Oxford and Swedish indexes were developed to predict in-hospital colectomy in acute severe ulcerative colitis (ASUC), but not long-term prediction, and all these indexes were based on Western data. Our study aimed to analyze the predictors of colectomy within 3 years of ASUC in an Indian cohort and derive a simple predictive score. Methods: A prospective observational study was conducted in a tertiary health care center in South India over a period of 5 years. All patients admitted with ASUC were followed up for a period of 24 months after the index admission, to look for progression to colectomy. Results: A total of 81 (47 male) patients were included in the derivation cohort. Fifteen (18.5%) patients required colectomy during a follow-up period of 24 months. On regression analysis, C-reactive protein (CRP) and serum albumin were independent predictors of 24-month colectomy. The CRAB (CRP + AlBumin) score was obtained by multiplying coefficient of beta to albumin and CRP (CRAB score = CRP x 0.2 – Albumin x 0.26). The CRAB score demonstrated an AUROC of 0.923 and a score of >0.4 with a sensitivity of 82% and specificity of 92% for the prediction of 2-year colectomy following ASUC. The score was validated in a validation cohort of 31 patients, and at >0.4, the score had a sensitivity of 83% and a specificity of 96% in predicting colectomy. Conclusion: CRAB score is a simple prognostic score that can predict 2-year colectomy in ASUC patients with high sensitivity and specificity