The etiology of the chronic
liver disease (CLD) in patients with
acute on chronic liver failure (ACLF) may vary from region to region. The major cause of underlying CLD is viral (
hepatitis B and C) in the East, while it is alcohol related in the West and in some parts of the Indian subcontinent. Autoimmune
liver disease and
Wilson's disease are the major underlying etiologies in the pediatric age group. The patients with CLD without
cirrhosis should be included when defining ACLF.
Non-alcoholic fatty liver disease related chronic liver insult in patients with known risk factors for progressive disease should be taken as a chronic
liver disease in the setting of ACLF, whereas
fatty liver with normal
aminotransferases in low risk patients should not. The patients with CLD and previous decompensation should be excluded. Diagnosis of chronic
liver disease in the setting of ACLF is made by history, physical examination and previously available or recent laboratory, endoscopic or radiological investigations. A liver biopsy through the transjugular route may help in cases where the presence of underlying CLD or its cause is not clear. The need of liver biopsy in ACLF should, however, be individualized. Standardization of liver biopsy assessment is essential for a uniform approach to the diagnosis and treatment of CLD and acute insult. Tools to measure liver stiffness may aid in identifying patients with advanced
fibrosis. Studies are needed to validate the performance of these tests in the setting of ACLF.