Stratification and selection of therapies to improve survival in severe alcoholic hepatitis

Table 4 Selection criterias for various therapies in severe alcoholic hepatitis

Therapy	Selection criteria	Remarks
Corticosteroids	Severe alcoholic hepatitis with mDF > 32 or MELD > 20 in absence of active sepsis and multiorgan dysfunctions. MELD > 39 should be avoided to exposed to corticosteroids	GI bleed and renal failure are relative contraindications. Corticosteroids can be considered on case to case basis in absence of other contraindications. Patients with resolved infections can be considered for steroid therapy
GCSF	Severe alcoholic hepatitis with mDF > 32 or MELD > 20 in absence of active sepsis and multiorgan dysfunctions. Patients with severe cytopenias, hemoglobin < 8 g/dL or leukocytosis with TLC > 30 k should be avoided for GCSF therapy. Patient with hypersplenism (spleen size > 15 cm) should be avoided	Limited literature exist regarding use of GCSF in resolved infection, GI bleed or Acute kidney injury. Hence it should be avoided till further evidence supports its use
Plasma exchange	Severe alcoholic hepatitis with mDF > 32 or MELD > 20 in absence of active sepsis and multiorgan dysfunctions. ACLF patients with progressive liver failure without extrahepatic failures are best candidates	Patients with acute renal injury in absence of other extrahepatic organ failure may benefit from therapy. Steroid non responders can be considered on case to case basis. Patients with GI bleed or resolved infection can be considered for plasma exchange
Fecal microbiota transplantation	Severe alcoholic hepatitis with mDF > 32 or MELD > 20 in absence of active sepsis and multiorgan dysfunctions	Patient with intestine paralysis should be avoided for FMT

MELD: Model for end stage liver disease; mDF: Maddrey’s discriminant function FMT: Fecal microbiota transplantation GI: Gastrointestinal; ACLF: Acute on chronic liver failure; GCSF: Granulocyte colony stimulating factor; TLC: Total leucocyte count.