Management of Acute-on-Chronic Liver Failure

Abstract

Acute-on-chronic liver failure (ACLF) is defined by the occurrence of organ failure(s) other than the liver in patients with cirrhosis. Even though mortality rates are high, there should no longer be reluctance to admit patients with ACLF in the intensive care unit. The prevalence of multidrug-resistant bacteria is high and broad spectrum antibiotics should be initiated as soon as infection is suspected. In patients with circulatory failure, the assessment of circulatory status is challenging due to the hyperkinetic state and an imbalance between the splanchnic and systemic blood volume. Acute kidney injury is common in patients with ACLF. Acute tubular necrosis should be differentiated from hepatorenal syndrome, which justifies vasoconstrictive agents. Renal replacement therapy and mechanical ventilation should be decided on clinical grounds. Recent trials on extracorporeal liver support failed to demonstrate a survival benefit. Aggressive management may serve as a bridge to transplantation provided patients are likely to survive after transplantation.

Fibroblast growth factor 21 is an early predictor of acute‐on‐chronic liver failure in critically ill patients with cirrhosis

“…As the syndrome evolves, many of these patients are referred to and treated in the ICU . To date, no specific therapies are available, except for antivirals in the case of ACLF induced by hepatitis B virus flare‐ups . This might be due to a lack of understanding of the pathogenesis, but also because in many patients, no obvious trigger can be identified .…”

“…(1)(2)(3)(4) To date, no specific therapies are available, except for antivirals in the case of ACLF induced by hepatitis B virus flare-ups. (22) This might be due to a lack of understanding of the pathogenesis, but also because in many patients, no obvious trigger can be identified. (23) Nevertheless, some first attempts have been undertaken to nonspecifically treat ACLF by means of liver transplantation, artificial liver support systems, plasma exchange, and granulocyte-colony stimulating factor.…”

Clinical states of cirrhosis and competing risks

“…Patients in state 6 and those with ACLF require a multidisciplinary approach to their management, with access to specific treatments and early selection of candidates for liver transplantation. [132][133][134] Competing risks in cirrhosis A competing risk is the risk of an event whose occurrence either precludes the occurrence of another event or modifies the probability that it will occur. Along the clinical course of cirrhosis, many clinical conditions, or states, may be characterised by competing outcomes which require competing risks analysis to correctly assess the relevant risks.…”

Stabilisation of acute‐on‐chronic liver failure patients before liver transplantation predicts post‐transplant survival

“…Acute‐on‐chronic liver failure (ACLF) is a clinical syndrome in patients with chronic liver disease that affects up to 30% of nonelectively hospitalised cirrhosis patients and is defined by hepatic and extrahepatic organ failures as well as exceedingly high short‐term mortality rates . Clinical management of ACLF includes the identification and elimination of precipitating factors and support of failing organs, yet a large number of ACLF patients fails to improve or even progresses towards multi‐organ failure resulting in death under conservative measures alone …”

“…[6][7][8][9] Clinical management of ACLF includes the identification and elimination of precipitating factors and support of failing organs, yet a large number of ACLF patients fails to improve or even progresses towards multi-organ failure resulting in death under conservative measures alone. 10 Orthotopic liver transplantation (OLT) is a widely accepted therapy for advanced-stage liver disease, but its role in the management of ACLF patients remains elusive. The majority of ACLF patients theoretically qualify for OLT listing based on current transplant guidelines, 11 yet only a minority ultimately undergo liver transplantation, 6,12 mainly due to contraindications for OLT (such as sepsis), or due to concerns that patients with multi-organ failure are "too sick for transplant,"…”