Liver failure

Acute-on-chronic liver failure

Reviewed Nov 2026·4 references
New· views rounded down, updated weekly

Define ACLF (EASL-CLIF and APASL), treat precipitants including alcoholic hepatitis and HBV flare, support organs, and decide on transplant or futility.

Definition
ACLF is acute decompensation of chronic liver disease with organ failures and high short-term mortality. EASL-CLIF: graded 1-3 by organ failures (CLIF-C OF score). APASL: jaundice (bilirubin ≥ 5 mg/dL) and coagulopathy (INR ≥ 1.5) complicated within 4 weeks by ascites and/or HE.

At the bedside

  1. 1

    Identify precipitant

    Infection (SBP, pneumonia, UTI), alcoholic hepatitis, HBV reactivation/flare, HEV/HAV superinfection, DILI, GI bleed. Culture all sites, diagnostic paracentesis.

  2. 2

    Grade

    Count organ failures (liver, kidney, brain, coagulation, circulation, respiration) using CLIF-C OF; calculate CLIF-C ACLF score or APASL AARC score.

  3. 3

    Treat infection early

    Empirical antibiotics according to local resistance (nosocomial: broader cover); start within 1 h if septic shock.

  4. 4

    Alcoholic hepatitis

    Maddrey DF ≥ 32 or MELD > 20 without infection/bleeding/AKI: prednisolone 40 mg/day; Lille at day 7 (≥ 0.45 = stop). Abstinence counselling.

  5. 5

    HBV

    Start tenofovir or entecavir immediately in HBV-related ACLF.

  6. 6

    Organ support

    Albumin for volume, noradrenaline ± terlipressin, CRRT, ventilation; HE care; avoid nephrotoxins and sedatives.

  7. 7

    Transplant evaluation

    Early referral; ACLF-2/3 have 28-day mortality 30-80% without transplant.

  8. 8

    Reassess at day 3-7

    Day 3-7

    If ≥ 4 organ failures or CLIF-C ACLF > 70 after 3-7 days of full support and not a transplant candidate, discuss limitation/palliation.

Severe alcoholic hepatitis

Prednisolone

Oral/NG
Dose
40 mg once daily for 28 days

Stop at day 7 if Lille ≥ 0.45.

HBV-related ACLF

Tenofovir disoproxil fumarate / entecavir

Oral/NG
Dose
Tenofovir DF 300 mg daily (or entecavir 0.5 mg daily)

EASL-CLIF ACLF grades (simplified)

GradeOrgan failuresApprox. 28-day mortality
No ACLFNone, or single non-kidney OF with creatinine < 1.5 and no HE~5%
ACLF-1Single kidney failure, or single other OF with creatinine 1.5-1.9 mg/dL and/or grade I-II HE~20-25%
ACLF-2Two organ failures~30-35%
ACLF-3Three or more organ failures~70-80%
Red flag · call your senior now
ACLF-3, particularly with ≥ 4 organ failures persisting after 3-7 days: very high mortality without transplant.
Pitfall
Starting steroids for alcoholic hepatitis without excluding infection.
Pitfall
Applying APASL and EASL definitions interchangeably: they select different populations.
Pearl
Each additional organ failure markedly increases mortality; count organ failures daily.

References

  1. 1

    European Association for the Study of the Liver. EASL Clinical Practice Guidelines on acute-on-chronic liver failure. J Hepatol 2023;79:461-91.

  2. 2

    Sarin SK, Choudhury A, Sharma MK, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update. Hepatol Int 2019;13:353-90.

  3. 3

    European Association for the Study of the Liver. EASL Clinical Practice Guidelines: management of alcohol-related liver disease. J Hepatol 2018;69:154-81.

  4. 4

    Louvet A, Naveau S, Abdelnour M, et al. The Lille model: a new tool for therapeutic strategy in patients with severe alcoholic hepatitis treated with steroids. Hepatology 2007;45:1348-54.

Test yourself

Module quiz · score 70% to complete the module

Previous

Acute liver failure and King's College criteria

Next

Hepatic encephalopathy

Educational reference for trained clinicians. Check doses against your hospital protocol and the patient in front of you.