Acute-on-Chronic Liver Failure

Patient Guideline Summary

Publication Date: January 10, 2022

Objective

Objective

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.

Overview

Overview

  • 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.

Diagnosis

Diagnosis

  • 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.

Treatment

Treatment

  • The severity of this condition requires the highest level of care and is best delivered in an intensive care unit (ICU).
  • Attention must be continuously paid to all vital organ systems — liver, kidney, brain, circulation and respiration. In addition, patients are at high risk of infection, bleeding, blood clots and bed sores.
  • Possible treatments include dialysis (artificially replacing kidney function), medications to raise blood pressure, antibiotics to treat infections, cortisone to suppress inflammation, artificial ventilation through an endotracheal tube (through the throat and into the lungs) or a tracheostomy (surgical opening into the wind pipe), liver transplant and meticulous attention to personal hygiene.
  • Each of these treatments has its risks as well as its benefits. The treatment team must choose among them, guided by the large volume of experience gained over years of intensive care study and practice.
  • 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.
  • Ultimately, despite the best efforts of skilled physicians, many patients with ACLF will die. Family and friends should prepare themselves and the patient for this outcome. Early legal planning removes a great deal of the burden associated with death.

Abbreviations

  • ACG: American College Of Gastroenterology
  • ACLF: Acute-on-chronic Liver Failure
  • ICU: Intensive Care Unit

Source Citation

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.

Disclaimer

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.