[Acute-on-chronic liver failure]

Acute-on-chronic liver failure (ACLF) is a life-threatening syndrome in patients with decompensated cirrhosis and is characterized by acute failure of one or more organ systems. Despite advances in clinical management, ACLF continues to be associated with high short-term mortality.This article provides an up-to-date, guideline-based overview of the classification, diagnosis, and therapeutic approaches to ACLF, drawing on the latest literature and consensus definitions.ACLF is defined by acute decompensation of cirrhosis accompanied by failure of the liver and/or other organs including the kidneys, cardiovascular system, lungs, central nervous system, and coagulation. The EASL-CLIF Consortium criteria distinguish three grades of ACLF based on the number and type of organ failures; increasing grade correlates with sharply rising short- and medium-term mortality. Pathophysiologically, ACLF is characterized by an overwhelming systemic inflammatory response typically triggered by bacterial infections, severe alcoholic hepatitis, or gastrointestinal bleeding. Prognostication is guided by CLIF-C OF, CLIF-C ACLF, and CLIF-C AD scores, which can also help to identify patients at high risk for further decompensation. Management focuses on rapid identification and reversal of precipitating factors, organ support, and early evaluation for liver transplantation, as it remains the sole curative option in non-reversible ACLF. Preemptive TIPS placement is reserved for selected cases, with individualized risk assessment being critical due to the increased complication rate in severe multiorgan failure.ACLF remains the most severe complication of cirrhosis, marked by high short-term mortality. Early, guideline-based interventions and multidisciplinary management can improve outcomes. Accurate risk stratification and timely consideration of liver transplantation are essential to enhance patient survival.