What is the management approach for acute on chronic liver failure?

Management Approach for Acute-on-Chronic Liver Failure (ACLF)

The management of acute-on-chronic liver failure requires early identification of precipitating events, aggressive organ support, consideration for liver transplantation, and appropriate palliative care consultation for all patients admitted to the ICU with ACLF, regardless of transplant listing status. 1

Initial Assessment and Stratification

• Assess ACLF grade and volume status before initiating treatment 1
• Evaluate oxygenation status (SpO2) - do not initiate vasopressors like terlipressin in patients with hypoxia (SpO2 <90%) 2
• Identify and treat precipitating factors:
  • Infections (bacterial, viral)
  • Alcoholic hepatitis
  • Gastrointestinal bleeding
  • Drug-induced liver injury

Organ-Specific Support

Respiratory Management

• Monitor oxygen saturation continuously using pulse oximetry 2
• Patients with fluid overload and ACLF Grade 3 are at increased risk for respiratory failure 2
• Consider mechanical ventilation for severe respiratory failure, but recognize this requires goals of care discussion if continuing >48 hours 1

Cardiovascular Support

• Maintain euvolemia with crystalloid fluids
• Consider colloids (albumin preferred) for fluid resuscitation 1
• For hepatorenal syndrome with rapid kidney function reduction:
  • Terlipressin 0.85 mg IV every 6 hours (adjust based on serum creatinine response) 2
  • Contraindicated in patients with hypoxia, worsening respiratory symptoms, or ongoing coronary/peripheral/mesenteric ischemia 2

Renal Support

• Avoid nephrotoxic drugs including NSAIDs 3
• Consider continuous renal replacement therapy (CVVH) rather than intermittent hemodialysis for acute renal failure 3
• For patients who are not transplant candidates with hepatorenal syndrome-acute kidney injury (HRS-AKI) unresponsive to pharmacotherapy, offer palliative care or hospice 1

Neurological Management

• Assess for and manage hepatic encephalopathy
• Avoid sedatives like benzodiazepines which can worsen encephalopathy 3

Infection Prevention and Management

• Consider broad-spectrum empirical antibiotics in patients with worsening hepatic encephalopathy or signs of systemic inflammatory response syndrome 3
• Monitor for infections, particularly fungal pathogens 3

Nutritional Support

• Initiate early enteral nutrition (60 grams of protein per day is reasonable) 3
• Monitor and replace phosphate, magnesium, and potassium as needed 3
• Manage hypoglycemia with continuous glucose infusions 3

Coagulopathy Management

• Administer fresh frozen plasma (FFP) and vitamin K for patients with severe coagulopathy 3
• Consider cryoprecipitate for hypofibrinogenemia unresponsive to FFP 3

Transplantation Evaluation

• Consider expedited liver transplantation for selected patients with ACLF 1
• Evaluate early for transplantation when prognostic indicators suggest high likelihood of death 3
• Note that certain treatments (like terlipressin) may cause adverse reactions that could make patients ineligible for transplantation 2

Palliative Care Integration

• All patients with cirrhosis admitted to the ICU or with a diagnosis of ACLF should receive a palliative care consult to define prognosis, determine goals of care, and document medical power of attorney and code status, regardless of transplant listing status 1
• Identify surrogate decision-maker within 48 hours of hospital admission 1
• For patients requiring mechanical ventilation >48 hours or ICU stay >48 hours, goals of care should be discussed and documented 1
• Offer palliative care or hospice to patients expected to survive <6 months 1
• Decisions about futility of care should be based on candidacy for expedited liver transplantation, available resources, and potential reversibility of ACLF 1

Prognostic Considerations

• Patients with ACLF and CLIF-C ACLF score ≥70 at 48 hours after intensive care have shown 100% 28-day mortality 1
• Patients with four or more organ failures at Days 3-7 after diagnosis of ACLF-3 have shown 90% and 100% mortality at 28 and 90 days, respectively 1
• For patients with high MELD scores (≥35), the benefits of certain treatments like terlipressin may not outweigh risks 2

Monitoring and Follow-up

• Monitor coagulation parameters (PT/INR, factor V) every 6-12 hours in severe cases 3
• Assess for signs of hepatic encephalopathy frequently 3
• Regular laboratory monitoring of liver function tests and other relevant parameters

The management of ACLF requires a multidisciplinary approach involving hepatologists, critical care specialists, transplant surgeons, and palliative care providers to optimize outcomes in this high-mortality condition.