# Acute-on-Chronic Liver Failure

Acute-on-chronic liver failure requires immediate identification of extrahepatic organ failure, reversal of precipitants, ICU-level organ support, and early transplant-center engagement. Serial assessment of organ dysfunction—not liver tests alone—determines prognosis, treatment intensity, and whether transplantation remains feasible.

**Clinical question:** How should physicians identify, stabilize, prognosticate, and triage patients with acute-on-chronic liver failure for transplantation?

Updated: 2026-08-24T16:27:41.004340+00:00

## What matters in practice
- Treat ACLF as a rapidly progressive multiorgan critical illness: identify and treat a precipitating event while supporting circulatory, respiratory, renal, and neurologic failure. [13][17]
- AASLD minimum components are acute clinical deterioration, liver failure with elevated bilirubin and INR in chronic liver disease, and at least one neurologic, circulatory, respiratory, or renal organ failure. [17]
- Protect the airway for Glasgow Coma Scale score 8 or lower or grade III-IV hepatic encephalopathy after evaluating alternative neurologic causes. [17]
- Obtain a diagnostic paracentesis when ascites is present and actively evaluate infection with blood and urine cultures; infection is common in ACLF and requires source-directed antimicrobial management. [10][19]
- Recalculate organ-failure severity during the first days of ICU care. A CLIF-C ACLF score above 70 at admission or day 3 was associated with approximately 90% 90-day mortality in a multicenter ICU cohort. [23]
- After stabilization, initiate rapid salvage liver-transplant evaluation because the window for transplantation may be narrow; advanced ACLF can have encouraging transplant outcomes in carefully selected patients. [5][13]

## Identify ACLF by acute deterioration plus organ failure

Separate ACLF from uncomplicated decompensation at first assessment because organ failure changes disposition and transplant urgency.

Use the AASLD minimum clinical construct: acute onset with rapid deterioration; liver failure manifested by elevated bilirubin and INR in chronic liver disease with or without cirrhosis; and at least one extrahepatic neurologic, circulatory, respiratory, or renal organ failure. Definitions vary across AASLD, EASL-CLIF, APASL, and NACSELD frameworks; document the system used rather than treating the ACLF label as interchangeable across studies. [7][17]

Escalate to ICU or a transplant-capable critical-care setting when organ failure is present or evolving. Under CLIF-OF criteria, shock despite adequate fluid resuscitation is defined by mean arterial pressure below 60 mm Hg or a fall in systolic blood pressure of 40 mm Hg from baseline; respiratory failure includes PaO2/FiO2 200 or lower, SpO2/FiO2 214 or lower, or mechanical-ventilation requirement. [1]

Do not classify an encephalopathic patient as having hepatic encephalopathy without excluding competing emergencies. Evaluate for intracranial hemorrhage, stroke, decompensated diabetes, psychiatric disease, and alcohol-associated dementia when clinically indicated. Intubate for airway protection with Glasgow Coma Scale score 8 or lower or grade III-IV hepatic encephalopathy. [17]
- At presentation, obtain CBC, coagulation profile, liver and renal chemistries, blood type and crossmatch when bleeding is possible, and blood and urine cultures. [19]
- Perform diagnostic paracentesis in any patient with ascites to assess for infection; ultrasound later in the admission can assess ascites, portal-vein flow, and an evident hepatic mass. [19]
- Calculate a liver severity score such as MELD or MELD-Na and an ACLF-specific organ-failure score such as CLIF-C ACLF; neither replaces serial bedside assessment. [7][10][23]

*Immediate organ-failure findings that should drive critical-care escalation. [1][17]*

| System | High-risk finding | Immediate action |
| --- | --- | --- |
| Neurologic | Grade III-IV hepatic encephalopathy or Glasgow Coma Scale score 8 or lower. [17] | Protect airway; evaluate for nonhepatic causes of altered mental status. [17] |
| Circulatory | Shock despite fluid resuscitation: mean arterial pressure below 60 mm Hg or systolic pressure decrease of 40 mm Hg from baseline. [1] | Initiate hemodynamic support and identify the precipitant, particularly infection or hemorrhage. [13][17] |
| Respiratory | PaO2/FiO2 200 or lower, SpO2/FiO2 214 or lower, or need for mechanical ventilation. [1] | Manage as respiratory failure in the ICU and reassess transplant candidacy as organ support evolves. [13] |
| Renal | Renal organ failure in the setting of ACLF, including suspected hepatorenal syndrome-AKI. [4][17] | Assess for reversible causes; use albumin plus vasoconstrictor therapy when HRS-AKI is diagnosed. [4] |

## Search immediately for reversible precipitants

Treat precipitants in parallel with organ support; waiting for full diagnostic closure risks losing transplant eligibility.

Infection, gastrointestinal hemorrhage, alcohol-associated hepatitis, and hepatic or extrahepatic injury can precipitate ACLF. In one contemporary cohort, bacterial infection occurred in 21.5% of ACLF admissions versus 13.3% of acute decompensation without ACLF; hepatorenal syndrome and hepatic encephalopathy were also more frequent in ACLF. [10]

For ascites, perform diagnostic paracentesis rather than relying on fever, leukocytosis, or abdominal symptoms. Obtain blood and urine cultures in parallel, and pursue source imaging or procedural source control when clinical findings indicate infection outside the peritoneum. Infection must be actively sought because it can be both a precipitant and a later complication of multiorgan failure. [7][19]

For suspected variceal hemorrhage, obtain CBC, coagulation testing, liver and renal chemistries, type and crossmatch, and arrange urgent endoscopic management. Terlipressin is used for suspected variceal bleeding at 2 mg IV every 4 hours in the cited guideline; peripheral vasoconstriction may manifest as painful hands and feet. [19]

When acute liver injury may represent acute liver failure rather than ACLF, do not accept a nodular liver on imaging as definitive cirrhosis: massive hepatic necrosis with regeneration can mimic cirrhosis radiographically. Promptly obtain viral hepatitis serologies including hepatitis A through E and autoimmune serologies; these results can identify treatable etiologies that change definitive therapy and transplant assessment. [16]
- Hemorrhage branch: evaluate for variceal bleeding, begin vasoactive therapy when suspected, and proceed to emergency endoscopy. [19]
- Ascites branch: diagnostic paracentesis is required to evaluate infection; use ultrasound guidance for large-volume paracentesis when available to reduce adverse events. [2][19]
- Hepatic injury branch: obtain hepatitis A-E and autoimmune serologies early when the chronicity of liver disease is uncertain or acute injury is disproportionate. [16]
- Renal branch: distinguish potentially reversible renal hypoperfusion or intrinsic injury from HRS-AKI before attributing renal failure solely to cirrhosis. Higher baseline creatinine predicts poorer response to vasoconstrictor treatment in HRS-AKI. [4]

*Precipitant-directed diagnostic actions in ACLF. [10][16][19]*

| Clinical pattern | Tests or procedures | Decision consequence |
| --- | --- | --- |
| Ascites with acute deterioration | Diagnostic paracentesis; blood and urine cultures. [19] | Identify peritoneal or systemic infection and institute antimicrobial therapy and source control as indicated. [7][19] |
| Upper gastrointestinal bleeding | CBC, coagulation profile, renal and liver tests, type and crossmatch; emergency endoscopy. [19] | Treat suspected portal-hypertensive bleeding with terlipressin and endoscopic hemostasis. [19] |
| Disproportionate acute hepatocellular injury or uncertain chronicity | Hepatitis A-E serologies and autoimmune serologies; interpret nodular imaging cautiously. [16] | Identify acute viral or autoimmune disease that changes cause-directed management and transplant planning. [16] |
| Worsening creatinine | Assess for HRS-AKI and competing renal etiologies; follow response to albumin and vasoconstrictor therapy when HRS-AKI is diagnosed. [4] | Baseline creatinine helps estimate likelihood of response and urgency of renal-support planning. [4] |

## Support failing organs while treating liver-specific complications

The immediate goal is to reverse precipitant-driven deterioration and preserve candidacy for recovery or liver transplantation.

Use a simultaneous management model: cardiovascular stabilization, circulatory support, airway protection, treatment of the precipitating event, and aggressive support of failing organs. Critical-care management should begin before all etiologic studies return because ACLF is characterized by high short-term mortality and may progress quickly. [13][17]

For hepatic encephalopathy, administer lactulose 20 g orally every hour as initial therapy in the cited AASLD educational guidance, while continuing to identify infection, bleeding, metabolic abnormalities, and alternative neurologic diagnoses. Airway protection takes priority over enteral administration in grade III-IV encephalopathy or when Glasgow Coma Scale score is 8 or lower. [17]

For HRS-AKI, use human albumin solution plus a vasoconstrictor, particularly terlipressin. Randomized trials cited in ascites guidance found that the terlipressin-albumin combination improves renal function and short-term mortality; a higher baseline creatinine predicts nonresponse. [4]

For tense or refractory ascites requiring large-volume paracentesis, give plasma expansion when more than 5 L are removed. Albumin is generally not required for removal of less than 5 L unless ACLF is present; in ACLF, albumin after lower-volume paracentesis reduced renal impairment, hyponatremia, and death in a study of 80 patients. [2][4]

Consider transjugular intrahepatic portosystemic shunt cautiously in advanced disease. Factors warranting caution include age over 70 years, bilirubin above 50 micromol/L, platelet count below 75 × 10^9/L, MELD score 18 or greater, current hepatic encephalopathy, active infection, or hepatorenal syndrome. [4]
- Reassess oxygenation, vasopressor requirement, mental status, renal function, and infection status repeatedly during the first 72 hours because dynamic organ dysfunction is more informative than a single admission assessment. [13][23]
- Use ultrasound guidance for large-volume paracentesis when available to reduce procedural adverse events. [2]
- Avoid delaying transplant referral until all organ failures resolve; stabilization and transplant evaluation should proceed in parallel. [13]

### When acute variceal bleeding coexists

Use terlipressin for suspected variceal hemorrhage and urgent endoscopic management. The cited guideline recommends terlipressin 2 mg IV every 4 hours and notes evidence of reduced failure to control bleeding and improved survival compared with placebo; monitor for ischemic peripheral vasoconstrictive effects. [19]

*Selected ACLF interventions with decision thresholds. [2][4][17][19]*

| Problem | Action | Threshold or important qualifier |
| --- | --- | --- |
| Severe encephalopathy | Intubate for airway protection; treat with lactulose 20 g orally every hour when enteral administration is safe. [17] | Glasgow Coma Scale score 8 or lower or grade III-IV encephalopathy supports intubation. [17] |
| HRS-AKI | Use albumin plus vasoconstrictor therapy, particularly terlipressin. [4] | Higher baseline creatinine predicts lower response probability. [4] |
| Large-volume paracentesis | Use plasma expansion. [2][4] | Always use when more than 5 L are removed. [2][4] |
| Paracentesis below 5 L | Consider albumin in ACLF. [2][4] | Routine plasma expansion is not necessary without ACLF. [2][4] |
| Suspected variceal bleeding | Terlipressin 2 mg IV every 4 hours plus emergency endoscopic management. [19] | Monitor for peripheral vasoconstriction. [19] |

## Use serial organ-failure scores to trigger transplant decisions

Prognosis should be updated after early resuscitation rather than inferred from baseline cirrhosis severity alone.

Track ACLF grade and CLIF-C ACLF score serially. In a multicenter ICU analysis, 90-day mortality was 33% with ACLF grade 1, 40% with grade 2, and 74% with grade 3 at admission. A CLIF-C ACLF score above 70 at admission or day 3 was associated with approximately 90% 90-day mortality. [23]

CLIF-C ACLF incorporates CLIF-OF, age, and white blood cell count. In an external prospective cohort summarized in a review, 28-day mortality was below 20% with CLIF-C ACLF below 45 and above 65% with a score above 65; this score may outperform Child-Pugh, MELD, and MELD-Na for ACLF prognostication in some cohorts. [9]

Refer early to a liver-transplant center after initial stabilization. Critical-care bridging aims to control precipitants and support organs so the patient can undergo salvage liver transplantation or recover; the window for transplantation may be narrow. Carefully selected patients with advanced ACLF can have encouraging post-transplant outcomes. [5][13]

Do not use a high prognostic score as an isolated declaration of futility. A CLIF-C ACLF score of 65 or greater predicts a lower likelihood of favorable outcome after liver transplantation, while trajectories of organ recovery, infection control, hemodynamic stability, and center-specific candidacy assessment remain central to the decision. [20][23]
- Repeat severity assessment by day 3, especially when initial ACLF grade is high or organ support is escalating. [23]
- Initiate transplant evaluation after stabilization rather than waiting for complete reversal of organ failure. [13]
- Integrate MELD or MELD-Na with ACLF-specific scores; in one cohort, 28-day mortality prediction was similar among MELD, MELD-Na, and CLIF-C ACLF. [10]

*Prognostic findings that should prompt time-sensitive goals-of-care and transplant discussions. [9][20][23]*

| Finding | Observed prognosis | Clinical use |
| --- | --- | --- |
| ACLF grade 1 at ICU admission | 90-day mortality 33% in a multicenter ICU cohort. [23] | Continue aggressive precipitant treatment and serial reassessment. [13][23] |
| ACLF grade 3 at ICU admission | 90-day mortality 74% in the same cohort. [23] | Urgently reassess trajectory, transplant feasibility, and goals of care. [13][23] |
| CLIF-C ACLF score above 70 at admission or day 3 | Approximately 90% 90-day mortality. [23] | Trigger multidisciplinary reassessment; do not rely on the score alone for transplant futility decisions. [20][23] |
| CLIF-C ACLF score 65 or greater | Lower likelihood of favorable post-transplant outcome. [20] | Use as one component of transplant selection alongside organ-function trajectory and clinical reversibility. [13][20] |

## Monitor for reversible trajectory and prevent recurrent decompensation

A favorable response is defined by improving organ function after precipitant control, not by bilirubin change alone.

During ICU care, use daily reassessment of vasopressor requirement, oxygenation or ventilator need, renal function, mental status, infection control, and ACLF score to determine whether the patient is improving toward transplantability or accumulating irreversible contraindications. Dynamic prognostication at day 3 adds clinically meaningful information beyond admission severity. [13][23]

After survival of the acute episode, address modifiable drivers of decompensated cirrhosis. The transition from compensated to decompensated cirrhosis is marked by ascites, variceal hemorrhage, or hepatic encephalopathy and is associated with an estimated 3- to 5-year survival; transplant evaluation is recommended in the absence of contraindications. Treat ongoing causal disease such as chronic viral hepatitis, alcohol exposure, or obesity as part of recurrence prevention. [1]

For patients not proceeding to transplantation because of persistent multiorgan failure, contraindications, or patient preferences, align ongoing organ support with prognosis and documented goals of care. Prognostic scores inform this conversation but should be interpreted alongside recovery trajectory and the possibility of reversible infection, bleeding, or renal dysfunction. [13][20][23]
- Document the ACLF definition and score used at each transition of care. [7][17]
- At discharge or transfer, communicate the precipitant, microbiology and source-control status, encephalopathy trajectory, renal-replacement needs if present, and transplant-center disposition. [13][19]
- Reassess TIPS suitability if ascites management remains difficult; active infection, current encephalopathy, hepatorenal syndrome, MELD score 18 or greater, bilirubin above 50 micromol/L, and platelets below 75 × 10^9/L warrant caution. [4]

## References
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## Editorial note

Prepared from cited clinical literature using Astra's research workflow. Verify recommendations against current guidance and patient-specific factors.