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The Critically Ill Cirrhotic Patient pp 193–217Cite as

Acute on Chronic Liver Failure

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Abstract

Acute on chronic liver failure (ACLF) describes a clinical syndrome characterized by (1) a patient with chronic liver disease that develops a (2) new or worsening hepatic decompensation with (3) marked dysfunction of other extrahepatic organs and (4) an increased short-term mortality. The physiologic changes in the liver and extrahepatic organs arise from sterile and non-sterile systemic inflammation and are compounded by a relatively immunocompromised state that exists in patients with chronic liver disease. Worldwide, infection is the most common etiology of ACLF. In Asia, hepatitis B flare or reactivation is the second most common, whereas alcohol and variceal hemorrhage are more common in Europe and North America. The management of ACLF should begin with hemodynamic and respiratory stabilization and a thorough infectious work-up with consideration of empiric antibiotics, in addition to management of other organ dysfunction(s). By definition, ACLF carries a high short-term mortality which is worsened by the number and degree of other extrahepatic organ dysfunctions. Many of these patients, though initially too sick to undergo transplantation, may improve to a point where they are considered transplant candidates with acceptable post-transplant outcomes. When improvement is not seen over several days, palliative care consultation should be considered.

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Abbreviations

ACLF:

Acute on chronic liver failure

APACHE-II:

Acute physiology and chronic health evaluation score II

APASL:

Asian Pacific Association for the Study of the Liver

CARS:

Compensatory anti-inflammatory response

CLIF-SOFA:

Chronic liver failure-sequential organ failure assessment

CpG:

Cytosine guanine

CTP:

Child-Turcotte-Pugh

DAMPs:

Damage-associated molecular patterns

EASL:

European Association for the Study of the Liver

Epi:

Epinephrine

FiO2:

Fraction of inspired oxygen

G-CSF:

Granulocyte colony-stimulating factor

GM-CSF:

Granulocyte-macrophage colony-stimulating factor

HMGB1:

Chromatin-associated protein high-mobility group box-1

IFN:

Interferon

IL:

Interleukin

LPS:

Lipopolysaccharide

MELD:

Model for End-Stage Liver Disease

MIP:

Macrophage inflammatory protein

NACSELD:

North American Consortium for the Study of End-Stage Liver Disease

NADH:

Nicotinamide adenine dinucleotide

NFκB:

Nuclear factor kappa-light-chain-enhancer of activated B cells

Nor:

Norepinephrine

PAMPs:

Pathogen-associated molecular patterns

PIRO:

Predisposition, injury, response, organ

PMN:

Polymorphonuclear

PSE:

Portosystemic encephalopathy

SBP:

Spontaneous bacterial peritonitis

SpO2:

Peripheral capillary oxygen saturation

Th1:

T helper cell type 1

Th2:

T helper cell type 2

TIPS:

Transjugular intrahepatic portosystemic shunt creation

TNF:

Tumor necrosis factor

TNF-α:

Tumor necrosis factor alpha

VCAM:

Vascular cell adhesion molecule

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  1. Division of Digestive and Liver Diseases, University of Texas Southwestern Medical Center, Dallas, TX, USA

    Mark R. Pedersen & Shannan R. Tujios

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    Robert S. Rahimi

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Pedersen, M.R., Tujios, S.R. (2020). Acute on Chronic Liver Failure. In: Rahimi, R. (eds) The Critically Ill Cirrhotic Patient. Springer, Cham. https://doi.org/10.1007/978-3-030-24490-3_11

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