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Liver Transpl. 2019 Nov 6. doi: 10.1002/lt.25675. [Epub ahead of print]

The development and outcome of acute-on-chronic liver failure after surgical interventions.

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Department of Internal Medicine I, University of Bonn, Germany.
Translational Hepatology, Department of Internal Medicine I, University Clinic, Frankfurt, Germany.
European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain.
Department of Gastroenterology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
Clinic for Surgery, University of Bonn, Germany.
GI/Liver Unit Hospital Clinic, University of Barcelona Institut d'Investigacions Biomèdiques August Pi-Sunyer (IDIBAPS, Barcelona, Spain.
Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark.
Institute for Bioengineering of Catalonia, Barcelona, Spain.



Acute-on-Chronic liver failure (ACLF) is a syndrome with high short-term mortality. Precipitating events including hemorrhage and infections contribute to ACLF development, but the role of surgery remains unknown. This analysis investigated development of ACLF in patients with cirrhosis undergoing surgery.


369 patients with cirrhosis were included in the study. The clinical and laboratory data were collected prior to and on days 1-2, 3-8 and 9-28, at three and 12 months after surgery. Surgery type was classified as limited or extensive, as well as liver and non-liver surgery.


A total of 39 patients had baseline ACLF. Surgery was performed during acute decompensation (AD) in 35% of the rest 330 patients and eighty-one (24.5%) developed ACLF within 28 days after surgery. Surrogate markers of systemic inflammation were similar in patients who developed ACLF or not. Age, sex, serum sodium, baseline bacterial infection and abdominal non-liver surgery were independent predictors for the development of ACLF after surgery. Patients who developed ACLF within 28 days after surgery had a higher mortality at 3, 6 and 12 months. Survival did not differ between patients with ACLF at surgery and those developing ACLF after surgery. Development of ACLF within 28 days after surgery, elevated alkaline phosphatase and INR were independent predictors of 90-day mortality. Independent predictors of one-year all-cause mortality were alkaline phosphatase, MELD score and pre-operative hepatic encephalopathy, while non-liver surgery was associated with improved survival.


ACLF frequently develops in cirrhotic patients undergoing surgery, especially in those with active bacterial infection, lower serum sodium and kidney or coagulation dysfunction. Prognoses of ACLF both at and after surgery are similarly poor. Cirrhotic patients should be carefully managed perioperatively.


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