Newswise — In patients with cirrhosis and chronic liver disease, acute-on-chronic liver failure is emerging as a major cause of mortality. New guidelines published January 10, 2022 in The American Journal of Gastroenterology indicate the preferred approach to the management of patients with acute-on-chronic liver failure and represent the official practice recommendations of the American College of Gastroenterology. The guidelines were developed by Jasmohan S. Bajaj, MD, MS, FACG; Jacqueline G. O'Leary, MD, MPH, FACG; Jennifer C. Lai, MD, MBA; Florence Wong, MD, FACG; Millie D. Long, MD, MPH, FACG (Methodologist); Robert J. Wong, MD, MS, FACG (Methodologist); and Patrick S. Kamath, MD.

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About Acute-on-Chronic Liver Failure
The authors write, “In patients with chronic liver disease, acute-on-chronic liver failure (ACLF), a relatively recently described entity, is diagnosed with a combination of hepatic and extrahepatic organ failures. The current definitions of ACLF vary worldwide, but despite these differences, patients with ACLF have a uniformly poor prognosis. The role of ACLF prediction, precipitating factors, individual organ failures, management strategies, and impact on liver transplantation or end-of-life care is evolving. The current guideline represents the synthesis of the current and emerging data on ACLF as a major entity in patients with chronic liver disease.”

The authors define Acute-on-Chronic Liver Failure as “a potentially reversible condition in patients with chronic liver disease with or without cirrhosis that is associated with the potential for multiple organ failure and mortality within 3 months in the absence of treatment of the underlying liver disease, liver support, or liver transplantation. ACLF is recognized by the presence of chronic liver disease along with elevation in the serum bilirubin and prolongation of the INR. The presence of kidney, lung, circulatory, or brain failure supports the diagnosis (Figure 1). The severity of organ failure may be assessed by the EASL-CLIF sequential organ failure assessment score or NACSELD organ failures score. Patients with ACLF are best managed in the intensive care unit (ICU), and some may benefit from early liver transplantation.”


[Figure 1.] Outlines of the 3 major ACLF definitions. ACLF, acute-on-chronic liver failure; APASL, Asian Pacific Association for the Study of the Liver; EASL CLIF-C, European Association for the Study of the Liver-Chronic Liver Failure Consortium; HE, hepatic encephalopathy; INR, international normalized ratio; MAP, mean arterial blood pressure; NACSELD, North American Consortium for the Study of End-Stage Liver Disease.