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PROGNOSTIC FACTORS IN SUB-ACUTE HEPATIC FAILURE: AN INDIAN PERSPECTIVE
U Zachariah1, S Choudhury1, C Eapen1, B Ramakrishna2, J Ramachandran1, A Mukhopadhya1, G Chandy1, G Kurian1
1Department of Gastrointestinal Sciences; 2Department of Pathology, Christian Medical College, Vellore, India
Aims: Sub-acute hepatic failure (SAHF) is a rare but distinct clinical condition described from India, characterized by persistent jaundice and features of hepatic decompensation in the form of ascites and / or encephalopathy within the fifth to twenty-fourth week after onset of jaundice in the absence of pre-existing chronic liver disease, with a mortality of 60-80%. The aim was to characterize the clinical profile and outcome of patients with SAHF and identify factors affecting the outcome.
Methods: This is a retrospective analysis of all patients admitted to the hepatology ward of our hospital with a diagnosis of SAHF from April 2006 to September 2008.
Results: Of 32 patients with SAHF with a mean age of 36±15, 21 (66%) were males. The mean duration of jaundice at admission was 60±32 days and time to decompensation 43±26 days. The etiologies were viral 11 (35%), including HBV 6 (19%), HEV 5 (16%) and HAV 1 (3%), drugs 8 (25%), autoimmune 1 (3%) and indeterminate 11 (34%). The mean MELD score at admission was 25±6. Only 10 (31%) had encephalopathy at the time of decompensation. 19 (59%) developed infections (spontaneous bacterial peritonitis in 18 [90%]). Transjugular liver biopsy was performed in 22 (69%) to rule out Acute-on-Chronic Liver Failure mimicking SAHF. The median duration of hospital stay was 11 (1-60) days. 11 (34%) patients died while 1 underwent cadaveric orthotopic liver transplantation. The age, sex, serum bilirubin, serum creatinine, PT (INR) and MELD at admission, presence of encephalopathy or infection and liver size by ultrasound had no bearing on the outcome (p=0.96, 0.44, 0.72, 0.12, 0.25, 0.14, 0.72, 0.45 and 1.0 respectively). The factors associated with mortality included shorter duration of jaundice (p=0.03), shorter time to decompensation (p=0.06) and worsening or new onset renal failure in hospital (p=0.02). On an ROC curve, worsening renal function had an area under the curve of 0.76, with a serum creatinine of 1.4 having a sensitivity of 64% and specificity of 81% at predicting mortality.
Conclusions: 1. While ascites was present in all patients with SAHF, encephalopathy was not a common cause of decompensation.
2. The overall prognosis in SAHF appears better than previously described.
3. Worsening renal failure in hospital determines mortality and can be used as a marker to consider patients with SAHF for liver transplantation.