Acute-on-chronic liver failure

Acute-on-chronic liver failure (ACLF) is a recently recognised and defined syndrome seen in patients with liver cirrhosis and carries a high short-term mortality in excess of 15% at 28 days. ACLF is defined by organ failures (OFs) and is distinct from simple 'acute decompensation' (AD) of cirrhosis. OFs involve the liver, kidney, brain, coagulation, respiratory system and the circulation, and are defined by the European Association for the Study of the Liver Chronic Liver Failure Consortium (CLIF-C) OF score. The central pathophysiological mechanism in the development of ACLF is intense systemic inflammation, which distinguishes this syndrome from AD. The most frequent precipitating event of ACLF in the western world is bacterial infection and active alcohol intake, whereas hepatitis B flare followed by sepsis and active alcohol intake are the common precipitating events in the east. In about 40% patients with ACLF, however, no precipitating event is found. The course of ACLF is dynamic and reversible, so early identification and early initiation of supportive therapy is of utmost importance. Unfortunately, to date, there is no known specific therapy for ACLF except for liver transplantation, so the treatment revolves around institution of early organ support. Most of the patients will have a clear prognosis between 3-7 days of hospitalisation. CLIF-C ACLF score is the best available prognostic score in patients with ACLF.