Hepatic Encephalopathy in Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure (ACLF) is characterized by the presence of chronic liver disease and extrahepatic organ failure and is associated with a high rate of short-term mortality. International societies have sought to define the criteria for ACLF and differ on definitions. Encephalopathy is an important organ failure in ACLF cases and is included as a marker of ACLF across society definitions. Both brain failure and ACLF commonly occur in the presence of a triggering event and in the setting of the large amount of inflammation that ensues. The presence of encephalopathy as a part of ACLF not only increases the chances of mortality but also provides unique challenges in that the patient will be limited in conversations around major decisions such as need for advanced level of care, liver transplant, or even end-of-life decisions. Many decisions need to be made quickly and occur in parallel in the care of patients with encephalopathy and ACLF and include stabilizing the patient, identifying precipitants or alternative diagnoses, and medical management. Infections has emerged as a major trigger for both ACLF and encephalopathy, and special attention should be given to identifying and treating infections as they occur.