Interview with Prof. Shiv K Sarin in the APASL2009

Hepatology Digest: Firstly I would like to thank you Dr Sarin for joining us here today at APASL 2009. It’s a great honour to speak to you today. The APASL Consensus Draft on Acute on Chronic Liver Failure was announced in the last APASL meeting, so at this new conference will there be any supplementary information, modifications or updates to it?

Dr Sarin: Thank you for inviting me. The Consensus now has been published in Hepatology International. The abstract book and the first issue of 2009 has all the details. As you will notice Acute on Chronic Liver Failure has now been defined as a development of jaundice and coagulopathy; you do a direct hepatic insult followed within four weeks by ascites and/or encephalopathy in a patient who has a recognized or unrecognized underlying chronic liver disease. And this definition has, from the beginning, no organ failure unlike the definition from the rest. So the whole idea of the Asia-Pacific working group is that we identify patients where the acute insult causing decompensation can be allowed to take over. In a patient who already has decompensated liver disease or advanced liver disease there is nothing much you can do except a transplant, but in Acute on Chronic Liver Failure, if you identify, without organ failure, then maybe these patients can benefit. Now tomorrow, that is February 14th, again there will be a three hour session on new definitions and further progress from twelve countries on Acute on Chronic Liver Failure in 2009.

Hepatology Digest: And when you talk about the classification, in terms of Acute on Chronic Liver Failure which involves the pre-existence of decompensated liver cirrhosis before the liver failure develops, there can be a confusion with chronic liver failure, so how can we talk about the differences between the therapy and the prognosis and identify which situation and which classification is correct?

Dr Sarin: The classification for liver failure is basically of acute liver failure, that is in a patient with no underlying non-liver disease, the patient gets jaundice and encephalopathy within a period of 4 weeks, although there are people who give it up to maybe 8 weeks or even 24 weeks. But Acute on Chronic Liver Failure is a distinct entity. There is no acute liver failure which means there is an underlying liver disease. The second entity is of a decompensated liver disease in which the patient has a known cirrhosis, he already has jaundice or ascites or encephalopathy. It is very serious. This is a different group. So Acute on Chronic Liver Failure falls in between. We have to be distinct from acute liver failure and distinct from a decompensated liver failure, and therefore now it is clear ACLF is a different and distinct entity.

Hepatology Digest: In regards to acute liver failure, it can happen with chronic HBV carriers because of the reactivation of the virus, so for those particular patients can antiviral therapy be used and how, if so?

Dr Sarin: Yes, it’s a very important question. In the etiology of Acute on Chronic Liver Failure, in the West, it is alcohol. If a patient who is drinking alcohol and has alcoholic cirrhosis goes onto a binge or drinks more, he gets alcoholic hepatitis. Or drugs are a common cause. While in the East, like in China or in India or the sub-continent, it is reactivation of Hepatitis B. It means the patient who is having a chronic HBV infection, gets a flare, means he gets high ALT, maybe more than five to ten times, and has got jaundice, has bilirubin and may even have presence of ascites or liver failure. In such patients whether to treat with antivirals or not is a very debatable issue. When you are given our latest studies which we have not published, the randomized controlled trial of twenty-five patients, thirteen were given antivirals, twelve were not given, there is a rapid decrease in the DNA, a rapid decrease in the ALT levels however there was no benefit in survival. So my recommendation is – patients who have a flare, they will have high DNA levels and then an antiviral like Tenofovir or maybe Telbivudine or Entecavir should be tried.

Hepatology Digest: How can we prevent the onset of Acute on Chronic Liver Failure during treatment of chronic viral hepatitis?

Dr Sarin: During treatment of chronic viral hepatitis, Acute on Chronic Liver Failure may generally not develop unless the patient with chronic Hepatitis B or C has a super-added viral infection, for example he gets an acute Hepatitis A or an acute Hepatitis E or a patient with Hepatitis C, gets an acute B or a patient with Hepatitis B gets acute C, so a super-added viral infection or a drug, say anti-tubercular therapy or a high dose of  (……..) or sometimes even some of these fungal, or like you have, mushrooms. So an acute insult has to be defined and these can be prevented but you can’t change the chronic liver disease.

Hepatology Digest: Thank you for joining us today Professor Sarin. It was our pleasure.

Dr Sarin: Thank you.