Acute-on-Chronic Liver Failure

Brain failure
In hospitalized patients with ACLF, we suggest the use of short-acting dexmedetomidine for sedation as compared to other available agents to shorten time to extubation (very low quality, conditional recommendation)

In patients with cirrhosis and ACLF who continue to require mechanical ventilation because of brain conditions or respiratory failure despite optimal therapy, we suggest against listing for LT to improve mortality (very low quality, conditional recommendation)


Kidney failure
In patients with cirrhosis and stages 2 and 3 AKI, we suggest IV albumin and vasoconstrictors as compared to albumin alone, to improve creatinine (low quality, conditional recommendation)

In patients with cirrhosis, we suggest against the use of biomarkers to predict the development of renal failure (very low quality, conditional recommendation)

In patients with cirrhosis and elevated baseline sCr who are admitted to the hospital, we suggest monitoring renal function closely because elevated baseline creatinine is associated with worse renal outcomes and 30-d survival (but no data that closer monitoring improves these outcomes) (very low quality, conditional recommendation)

In hospitalized patients with cirrhosis and HRS-AKI without high grade of ACLF or major cardiopulmonary or vascular disease, we suggest terlipressin (moderate quality, conditional recommendation) or norepinephrine (low quality, conditional recommendation) to improve renal function

In patients with cirrhosis and SBP, we recommend albumin in addition to antibiotics to prevent AKI and subsequent organ failures (high quality, strong recommendation)

In patients with cirrhosis and infections other than SBP, we recommend against albumin to improve renal function or mortality (high quality, strong recommendation)


Respiratory failure
In ventilated patients with cirrhosis, we suggest against prophylactic antibiotics to reduce mortality or duration of mechanical ventilation (very low quality, conditional recommendation)


Coagulation failure
In patients with cirrhosis and ACLF, we suggest against INR as a means to measure coagulation risk (very low quality, conditional recommendation)

In patients with cirrhosis as compared to noncirrhotic populations, we suggest there is an increased risk of VTE (low quality, conditional recommendation)

In patients with ACLF and altered coagulation parameters, we suggest against transfusion in the absence of bleeding or a planned procedure (low quality, conditional recommendation)

In patients with cirrhosis who require invasive procedures, we recommend the use of TEG or ROTEM, compared with INR, to more accurately assess transfusion needs (moderate quality, conditional recommendation)


Infections
In hospitalized decompensated cirrhotic patients, we recommend assessment for infection because infection is associated with the development of ACLF and increased mortality (moderate quality, strong evidence)

In patients with cirrhosis and suspected infection, we suggest early treatment with antibiotics to improve survival (very low quality, conditional evidence)


Nosocomial and fungal infections
In hospitalized patients with ACLF because of a bacterial infection who have not responded to antibiotic therapy, we suggest suspicion of a MDR organism or fungal infection to improve detection (very low quality, conditional recommendation)


Medications and prophylaxis for infection
In patients with cirrhosis with a history of SBP, we suggest use of antibiotics for secondary SBP prophylaxis to prevent recurrent SBP (unable to comment on specific antibiotic choice) (low quality, conditional recommendation)

In patients with cirrhosis in need of primary SBP prophylaxis, we suggest daily prophylactic antibiotics, although no one specific regimen is superior to another, to prevent SBP (low quality, conditional recommendation)

In patients with cirrhosis, we suggest avoiding PPI unless there is a clear indication because PPI increases the risk of infection (very low quality, conditional recommendation)


Alcohol-associated hepatitis
In patients with severe alcohol-associated hepatitis (MDF ≥ 32; MELD score > 20) in the absence of contraindications, we recommend the use of prednisolone or prednisone (40 mg/d) orally to improve 28-d mortality (moderate quality, strong recommendation)

In patients with severe alcohol-associated hepatitis (MDF ≥ 32; MELD score > 20), we suggest against the use of pentoxifylline to improve 28-d mortality (very low quality, conditional recommendation)


Management strategies
In patients with cirrhosis who are hospitalized, we suggest against the routine use of parenteral nutrition, enteral nutrition, or oral supplements to improve mortality

In hospitalized patients with cirrhosis, we recommend against daily infusion of albumin to maintain albumin >3 g/dL to improve mortality, prevention of renal dysfunction, or infection (moderate quality, strong recommendation)

In patients with cirrhosis and ACLF, we suggest against the use of G-CSF to improve mortality (very low evidence, conditional recommendation)


Transplant vs futility
In patients with cirrhosis and ACLF who continue to require mechanical ventilation because of ARDS or brain-related conditions despite optimal therapy, we suggest against listing for LT to improve mortality (very low evidence, conditional recommendation)

In patients with end-stage liver disease admitted to the hospital, we suggest early goals of care discussion and if appropriate, referral to palliative care to improve resource utilization (very low evidence, conditional recommendation)