Acute on chronic liver failure

Acute on chronic liver failure (ACLF) describes a clinical syndrome characterized by (1) a patient with chronic liver disease that develops a (2) new or worsening hepatic decompensation with (3) marked dysfunction of other extrahepatic organs and (4) an increased short-term mortality. The physiologic changes in the liver and extrahepatic organs arise from sterile and non-sterile systemic inflammation and are compounded by a relatively immunocompromised state that exists in patients with chronic liver disease. Worldwide, infection is the most common etiology of ACLF. In Asia, hepatitis B flare or reactivation is the second most common, whereas alcohol and variceal hemorrhage are more common in Europe and North America. The management of ACLF should begin with hemodynamic and respiratory stabilization and a thorough infectious work-up with consideration of empiric antibiotics, in addition to management of other organ dysfunction(s). By definition, ACLF carries a high short-term mortality which is worsened by the number and degree of other extrahepatic organ dysfunctions. Many of these patients, though initially too sick to undergo transplantation, may improve to a point where they are considered transplant candidates with acceptable post-transplant outcomes. When improvement is not seen over several days, palliative care consultation should be considered.