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Critical Care329 papers

Acute on chronic liver failure

Last edited: 4/16/2026

Overview

Acute on chronic liver failure (ACLF) is a syndrome characterized by acute deterioration in patients with underlying chronic liver disease, often leading to multiorgan dysfunction and high mortality 2822.

Diagnosis

  • Clinical Presentation: Rapid deterioration in liver function with evidence of organ failure beyond the liver 28.
  • Laboratory Tests: Elevated liver enzymes, coagulopathy (INR >1.5), and markers of organ dysfunction (e.g., creatinine, bilirubin) 222.
  • Grading Systems: Use of models like CLIF-SOFA score to assess severity and predict prognosis 27.
  • Specific Etiologies: Identification of precipitating factors such as infection, variceal bleeding, or hepatotoxic agents 22242.
  • Management

  • Supportive Care: Intensive care unit management, hemodynamic stabilization, and management of complications like encephalopathy and infections 1831.
  • Liver Support Systems: Use of artificial liver support systems like MARS (Molecular Adsorbent Recirculating System) for patients with severe ACLF 5949.
  • Therapeutic Plasma Exchange (TPE): Consideration in selected cases to manage systemic inflammation and multiorgan failure 1731.
  • Liver Transplantation: Indicated for patients with refractory ACLF and multiorgan failure, with careful selection based on prognostic models 213668.
  • Targeted Therapies: Granulocyte-colony stimulating factor (G-CSF) for potential reduction in mortality 45.
  • Special Populations

  • Pediatrics: Timely diagnosis and management crucial; guidelines emphasize supportive care and early transplantation if needed 3713141516.
  • Elderly: Consideration of frailty and comorbidities in decision-making for liver transplantation 66.
  • Comorbidities: Management of underlying conditions like sepsis, infections, and coagulopathy is essential 13141.
  • Key Recommendations

  • Early Identification and Supportive Care: Implement intensive supportive care measures in patients with suspected ACLF to stabilize hemodynamics and manage organ failures (Evidence: Strong 18).
  • Use of Artificial Liver Support Systems: Consider MARS or similar systems for patients with severe ACLF and multiorgan failure to improve survival (Evidence: Moderate 5949).
  • Prognostic Models for Transplantation: Utilize prognostic models like CLIF-SOFA to guide decisions for emergent liver transplantation in ACLF (Evidence: Moderate 2721).
  • Therapeutic Plasma Exchange: Evaluate TPE in selected cases of ACLF with severe systemic inflammation and multiorgan failure (Evidence: Weak 1731).
  • Targeted Therapies: Consider G-CSF in patients with ACLF to potentially reduce mortality, particularly in those with high inflammatory markers (Evidence: Moderate 45).
  • References

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The American journal of gastroenterology 2024. link 5 Yessayan LT, Sharma P, Westover AJ, Szamosfalvi B, Humes HD. Extracorporeal Immunomodulation Therapy in Acute Chronic Liver Failure With Multiorgan Failure: First in Human Use. ASAIO journal (American Society for Artificial Internal Organs : 1992) 2024. link 6 Ahmad S, Novokhodko A, Liou IW, Smith NC, Carithers RL, Reyes J et al.. Development and First Clinical Use of an Extracorporeal Artificial Multiorgan System in Acute-on-Chronic Liver Failure Patients. ASAIO journal (American Society for Artificial Internal Organs : 1992) 2024. link 7 Alam S, Lal BB. Pediatric Acute-on-Chronic Liver Failure. Indian journal of pediatrics 2024. link 8 Pompili E, Iannone G, Carrello D, Zaccherini G, Baldassarre M, Caraceni P. Managing Multiorgan Failure in Acute on Chronic Liver Failure. Seminars in liver disease 2024. link 9 Li G, Zhang P, Zhu Y. Artificial liver support systems for hepatitis B virus-associated acute-on-chronic liver failure: A meta-analysis of the clinical literature. Journal of viral hepatitis 2023. link 10 Rosenberg K. New Guidelines Issued for Diagnosis and Management of Acute Liver Failure. The American journal of nursing 2023. link 11 Shingina A, Mukhtar N, Wakim-Fleming J, Alqahtani S, Wong RJ, Limketkai BN et al.. Acute Liver Failure Guidelines. The American journal of gastroenterology 2023. link 12 Saeidinejad M, Elshabrawi A, Sriphoosanaphan S, Andreola F, Mehta G, Agarwal B et al.. Novel Therapeutic Approaches in Treatment of Acute-on-Chronic Liver Failure. Seminars in liver disease 2023. link 13 Mishra S, Pallavi P. Diagnosis and Management of Pediatric Acute Liver Failure: ESPGHAN and NASPGHAN 2022. Indian pediatrics 2022. link 14 Zellos A, Debray D, Indolfi G, Czubkowski P, Samyn M, Hadzic N et al.. Proceedings of the European Society for Pediatric Gastroenterology, Hepatology and Nutrition Monothematic Conference, 2020: "Acute Liver Failure in Children": Treatment and Directions for Future Research. Journal of pediatric gastroenterology and nutrition 2022. link 15 Zellos A, Debray D, Indolfi G, Czubkowski P, Samyn M, Hadzic N et al.. Proceedings of ESPGHAN Monothematic Conference 2020: "Acute Liver Failure in Children": Diagnosis and Initial Management. Journal of pediatric gastroenterology and nutrition 2022. link 16 Squires JE, Alonso EM, Ibrahim SH, Kasper V, Kehar M, Martinez M et al.. North American Society for Pediatric Gastroenterology, Hepatology, and Nutrition Position Paper on the Diagnosis and Management of Pediatric Acute Liver Failure. Journal of pediatric gastroenterology and nutrition 2022. link 17 Alexander EC, Deep A. Therapeutic plasma exchange in children with acute liver failure (ALF): is it time for incorporation into the ALF armamentarium?. Pediatric nephrology (Berlin, Germany) 2022. link 18 Sabapathy DG, Desai MS. Acute Liver Failure in Children. Pediatric clinics of North America 2022. link 19 Mu X, Tong J, Xu X, Chen J, Su H, Liu X et al.. World Gastroenterology Organisation classification and a new type-based prognostic model for hepatitis B virus-related acute-on-chronic liver failure. Clinics and research in hepatology and gastroenterology 2021. link 20 Tang X, Qi T, Li B, Li H, Huang Z, Zhu Z et al.. Tri-typing of hepatitis B-related acute-on-chronic liver failure defined by the World Gastroenterology Organization. Journal of gastroenterology and hepatology 2021. link 21 Kim JE, Sinn DH, Choi GS, Kim JM, Joh JW, Kang W et al.. Predictors and outcome of emergent Liver transplantation for patients with acute-on-chronic liver failure. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2021. link 22 Karvellas CJ, Speiser JL, Tremblay M, Lee WM, Rose CF. Elevated Serum Liver-Type Fatty Acid Binding Protein Levels in Non-acetaminophen Acute Liver Failure Patients with Organ Dysfunction. Digestive diseases and sciences 2021. link 23 Nautiyal N, Maheshwari D, Tripathi DM, Kumar D, Kumari R, Gupta S et al.. Establishment of a murine model of acute-on-chronic liver failure with multi-organ dysfunction. Hepatology international 2021. link 24 Tomescu D, Popescu M, David C, Sima R, Dima S. Haemoadsorption by CytoSorb® in patients with acute liver failure: A case series. The International journal of artificial organs 2021. link 25 Arshad MA, Murphy N, Bangash MN. Acute liver failure. Clinical medicine (London, England) 2020. link 26 Dong V, Nanchal R, Karvellas CJ. Pathophysiology of Acute Liver Failure. Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition 2020. link 27 Chen W, You J, Chen J, Zhu Y. Combining the serum lactic acid level and the lactate clearance rate into the CLIF-SOFA score for evaluating the short-term prognosis of HBV-related ACLF patients. Expert review of gastroenterology & hepatology 2020. link 28 Hyde R, Chung J, Faruqi I. A 36-Year-Old Woman Presenting With Left Upper Quadrant Discomfort, Encephalopathy, and Respiratory Failure. Chest 2020. link 29 Thuluvath PJ, Thuluvath AJ, Savva Y, Zhang T. Karnofsky Performance Status Following Liver Transplantation in Patients With Multiple Organ Failures and Probable Acute-on-Chronic Liver Failure. Clinical gastroenterology and hepatology : the official clinical practice journal of the American Gastroenterological Association 2020. link 30 Sardar D, Mathews N, Mammen J, Nair SC, Jacob S, Patel L et al.. Rodenticidal hepatotoxicity: Raised plasma Von Willebrand factor levels predict in-hospital survival and preliminary report of the outcome of Von Willebrand factor reducing management protocol. Indian journal of gastroenterology : official journal of the Indian Society of Gastroenterology 2019. link 31 Stahl K, Hadem J, Schneider A, Manns MP, Wiesner O, Schmidt BMW et al.. Therapeutic plasma exchange in acute liver failure. Journal of clinical apheresis 2019. link 32 Hamdi T. Pathogenesis of cerebral edema in patients with acute renal and liver failure and the role of the nephrologist in the management. Current opinion in nephrology and hypertension 2018. link 33 Kim YJ, Lee HJ, Ryoo SM, Ahn S, Sohn CH, Seo DW et al.. Prognostic value of decision criteria for emergency liver transplantation in patients with wild mushroom induced acute liver injury. Hepatobiliary & pancreatic diseases international : HBPD INT 2018. link 34 Mehrotra S, Mehta N, Rao PS, Lalwani S, Mangla V, Nundy S. Live donor liver transplantation for acute liver failure: A single center experience. Indian journal of gastroenterology : official journal of the Indian Society of Gastroenterology 2018. link 35 Maiwall R, Jamwal KD, Bhardwaj A, Bhadoria AS, Maras JS, Kumar G et al.. SX-Ella Stent Danis Effectively Controls Refractory Variceal Bleed in Patients with Acute-on-Chronic Liver Failure. Digestive diseases and sciences 2018. link 36 Michard B, Artzner T, Lebas B, Besch C, Guillot M, Faitot F et al.. Liver transplantation in critically ill patients: Preoperative predictive factors of post-transplant mortality to avoid futility. Clinical transplantation 2017. link 37 Audimoolam VK, McPhail MJ, Willars C, Bernal W, Wendon JA, Cecconi M et al.. Predicting Fluid Responsiveness in Acute Liver Failure: A Prospective Study. Anesthesia and analgesia 2017. link 38 Choudhury A, Kumar M, Sharma BC, Maiwall R, Pamecha V, Moreau R et al.. Systemic inflammatory response syndrome in acute-on-chronic liver failure: Relevance of 'golden window': A prospective study. Journal of gastroenterology and hepatology 2017. link 39 Yang R, Zou X, Tenhunen J, Tønnessen TI. HMGB1 and Extracellular Histones Significantly Contribute to Systemic Inflammation and Multiple Organ Failure in Acute Liver Failure. Mediators of inflammation 2017. link 40 Sparks BE, Cavarocchi NC, Hirose H. Extracorporeal membrane oxygenation with multiple-organ failure: Can molecular adsorbent recirculating system therapy improve survival?. The Journal of heart and lung transplantation : the official publication of the International Society for Heart Transplantation 2017. link 41 Donnelly MC, Hayes PC, Simpson KJ. Role of inflammation and infection in the pathogenesis of human acute liver failure: Clinical implications for monitoring and therapy. World journal of gastroenterology 2016. link 42 Shalimar, Kumar D, Vadiraja PK, Nayak B, Thakur B, Das P et al.. 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