Hepatology International

, Volume 12, Issue 5, pp 402–416 | Cite as

Management of acute-on-chronic liver failure: an algorithmic approach

  • Shiv Kumar SarinEmail author
  • Ashok Choudhury
Review Article


Acute-on-chronic liver failure (ACLF) is a distinct syndrome of liver failure in a patient with chronic liver disease presenting with jaundice, coagulopathy and ascites and/or hepatic encephalopathy, developing following an acute hepatic insult and associated with high 28-day mortality. The definition though lacks global consensus, excludes patients with known distinct entities such as acute liver failure and those with end-stage liver disease. The initial Systemic Inflammatory Response Syndrome (SIRS) because of cytokine storm in relation to acute insult and/or subsequent development of sepsis due to immunoparalysis leads to extrahepatic organ failure. These cascades of events progress through a ‘Golden Window’ period of about 7 days, subsequent to which majority of the patients develop complications, such as sepsis and extrahepatic organ failure. Prevention of sepsis, support of organs and management of organ failure (commonly hepatic, renal, cerebral, coagulation) and early referral for transplant is crucial. The APASL ACLF research consortium (AARC) liver failure score is a dynamic prognostic model for management decisions and is superior to existing models. Aggressive multidisciplinary approach can lead to a transplant-free survival in nearly half of the cases. The present review provides an algorithmic approach to management of organ failure, sepsis prevention, use of dynamic prognostic models for management decision and is aimed to improve the skills for managing and improving the outcomes of such critically ill patients.


Liver failure Organ failure ACLF APASL 



APASL ACLF research consortium


Acute decompensation


Acute-on-chronic liver failure


Compensated anti-inflammatory response syndrome


Damage associated molecular pattern


End stage liver disease


Pathogen Associated Molecular Pattern


Systemic inflammatory response syndrome


Severe alcoholic hepatitis



Authors are grateful to R. K. Gulati for his intellectual inputs and proof reading.

Author contributions

AC drafted the manuscript and designed the sections and designed the figures. SKS edited the manuscript, revised the sections and prepared the final version.

Compliance with ethical standards

Conflict of interest

Shiv K Sarin and Ashok Choudhury declare that they have no conflict of interest.


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Copyright information

© Asian Pacific Association for the Study of the Liver 2018

Authors and Affiliations

  1. 1.Department of Hepatology and Liver TransplantInstitute of Liver and Biliary SciencesNew DelhiIndia

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