Designed and created by Guideline Central in participation with the American College of Gastroenterology
Acute-on-Chronic Liver Failure
Patient Guideline Summary
Publication Date: January 10, 2022
Last Updated: November 3, 2023
This patient summary discusses key recommendations from the American College of Gastroenterology (ACG) for acute-on-chronic liver failure. It is limited to adults 18 years of age and older and should not be used as a reference for children.
- We will use the abbreviation ACLF throughout this summary to refer to acute-on-chronic liver failure.
- ACLF describes a new (acute) liver disease on top of an existing (chronic) liver disease.
- ACLF is a potentially reversible condition in patients with chronic liver disease with or without cirrhosis. It can also cause multiple organ failure and death within 3 months in the absence of treatment of the underlying liver disease, liver support, or liver transplantation.
- This patient summary represents the synthesis of the current and emerging data on ACLF as a major entity in patients with chronic liver disease.
- In a patient with chronic liver disease, ACLF presents with bleeding and jaundice followed within 4 weeks by ascites (excess fluid in the abdomen) and/or dementia. These are all signs of a failing liver.
- Confirming laboratory tests include elevation in the serum bilirubin (causing jaundice) and prolongation of the INR (a blood test that indicates how well the blood is able to clot). Kidney, lung and circulatory failure can follow, often causing death within 3 months.
- For sedated patients with ACLF, short-acting dexmedetomidine may allow faster removal from breathing machines compared to other sedatives.
- If a patient with ACLF requires prolonged breathing machine support due to brain or lung problems despite optimal treatment, liver transplant may not improve survival.
- Giving albumin with vasoconstrictors may improve kidney function better than albumin alone in patients with cirrhosis and stages 2-3 acute kidney injury (AKI).
- Biomarkers are not routinely used to predict kidney failure since evidence is lacking.
- Close monitoring of kidney function in hospitalized patients with high baseline creatinine is recommended.
- Terlipressin or norepinephrine may improve kidney function in ACLF without major cardiopulmonary disease.
- Albumin with antibiotics is given for spontaneous bacterial peritonitis (SBP) to prevent kidney failure.
- Antibiotics are not routinely given to patients with cirrhosis on a breathing machine since it may not improve outcomes.
- INR (a blood test that measures how long it takes your blood to clot) is not recommended to assess coagulation risk in ACLF.
- Patients with cirrhosis have increased blood clot risk.
- Blood products are not recommended unless there is bleeding or planned procedures.
- Specialized blood clotting tests are recommended over INR to guide blood product use.
- Infections will be assessed in decompensated cirrhosis since it increases ACLF risk and mortality.
- Early antibiotics improve survival in suspected infections.
- Resistant bacteria or fungi can be the cause if infection persists despite antibiotics.
- Secondary prophylaxis antibiotics are given in patients with prior SBP.
- Primary prophylaxis antibiotics are given to patients at high risk.
- Gastric acid reducers should be avoided if not clearly indicated since they increase the risk of infections.
- Prednisolone or prednisone (cortisone-like steroids) are given for severe alcoholic hepatitis.
- Pentoxifylline is not recommended.
- Routine nutrition supplementation is not required.
- Daily albumin infusions are not recommended.
- Granulocyte colony-stimulating factor (G-CSF) is not recommended.
- Liver transplant may not improve mortality if the patient requires prolonged breathing machine support for brain or lung issues despite other treatments.
- Since patients will frequently be unable to communicate due to breathing support or diminished mental capacity, the presence of family or friends familiar with the patient’s wishes is an essential addition to the decision-making process.
- ACG: American College Of Gastroenterology
- ACLF: Acute-on-chronic Liver Failure
- AKI: Acute Kidney Injury
- G-CSF: Granulocyte Colony-stimulating Factor
- INR: International Normalized Ratio
- SBP: Spontaneous Bacterial Peritonitis
Bajaj JS, O'Leary JG, Lai JC, Wong F, Long MD, Wong RJ, Kamath PS. Acute-on-Chronic Liver Failure Clinical Guidelines. Am J Gastroenterol. 2022 Feb 1;117(2):225-252. doi: 10.14309/ajg.0000000000001595. PMID: 35006099.
The information in this patient summary should not be used as a substitute for professional medical care or advice. Contact a health care provider if you have questions about your health.