From the Guidelines
Initial management of suspected acute on chronic liver failure (ACLF) requires prompt hospitalization in an intensive care setting with a multidisciplinary approach, as recommended by the most recent guidelines 1. The first step is to identify and treat the precipitating factor, which commonly includes infections (particularly spontaneous bacterial peritonitis), alcoholic hepatitis, drug toxicity, or gastrointestinal bleeding.
- Administer broad-spectrum antibiotics such as ceftriaxone 1-2g IV daily or piperacillin-tazobactam 4.5g IV every 6-8 hours if infection is suspected, pending culture results, as suggested by recent practice guidance 1.
- Provide hemodynamic support with careful fluid resuscitation using albumin 1g/kg/day if needed, while avoiding excessive fluid administration that could worsen ascites.
- Monitor for and treat complications including hepatic encephalopathy (with lactulose 25-30ml orally every 1-2 hours until bowel movements occur, then 15-30ml 2-3 times daily), coagulopathy (with vitamin K 10mg IV daily for 3 days), renal dysfunction (avoid nephrotoxic medications), and electrolyte imbalances. Key considerations in the management of ACLF include:
- Nutritional support is crucial, with 1.2-1.5g/kg/day of protein and 35-40 kcal/kg/day caloric intake.
- Perform daily assessments using prognostic scores like MELD or CLIF-SOFA to guide treatment intensity and consideration for liver transplantation evaluation in appropriate candidates, as recommended by the European Association for the Study of the Liver 1. This comprehensive approach addresses the multisystem nature of ACLF and targets both the acute insult and underlying chronic liver disease, ultimately aiming to reduce morbidity, mortality, and improve quality of life 1.
From the Research
Initial Management for Acute on Chronic Liver Failure (ACLF)
The initial management for a patient with suspected acute on chronic liver failure (ACLF) involves several key steps:
- Identification of the underlying cause of ACLF, such as bacterial infection, gastrointestinal hemorrhage, viral hepatitis, or recent excessive alcohol intake 2
- Assessment of the severity of organ failures using clinical scoring tools, such as the liver-adapted sequential organ assessment failure score 3
- Provision of supportive care, including management of complications such as encephalopathy, coagulopathy, and hemodynamic instability 4, 5
- Consideration for admission to intensive care unit (ICU) for close monitoring and management of organ failures 2
- Evaluation for liver transplantation in patients with poor prognostic factors 6, 3
Organ Failure Management
The management of organ failures in ACLF is crucial to improve patient outcomes:
- Hepatic encephalopathy: managed with ammonia-lowering agents and other supportive measures 6
- Coagulopathy: managed with blood products and other supportive measures 4, 5
- Hemodynamic instability: managed with vasopressors and other supportive measures 4, 5
- Renal injury: managed with renal replacement therapy and other supportive measures 4, 5
Prognostication and Clinical Decision-Making
Prognostication is critical in ACLF to guide clinical decision-making: