Acute on Chronic Liver Failure (ACLF)

  • WGO (World Gastroenterology Organisation) working definition:
  • It is a syndrome in patients with chronic liver disease with or without cirrhosis characterized by
  • – Acute decompensation resulting in liver failure(jaundice,prologed INR)
  • -One or more extrahepatic organ failure
  • -Associated with increased mortality within a period of 28 days and upto 3 months from onset.
  • APASL definition:
  • – An acute hepatic insult manifesting as jaundice and coagulopathy, complicated within 4 weeks by ascites and/or encephalopathy with high 28 day mortality
  • EASL-CLIF definition:
  • – Acute decompensation (AD) of cirrhosis associated with organ failure and high short-term mortality (28 day mortality 15%)


NACSELD(North American consortium for study of End-Stage Liver Disease) definition of extrahepatic organ failures:

CIRCULATORY= Shock= MAP <60 mm Hg or reduction of systolic BP 40 mm Hg from baseline despite adequate fluid resuscitation and cardiac output.

Brain=Grade 3-4 hepatic failure.

Renal= Requiring dialysis or other form of renal replacement therapy

Respiratory= requiring mechanical ventilation

  • Classification of ACLF (according to WGO- world gastroenterology organization)
  •  Type A ACLF: Patients with underlying non-cirrhotic chronic liver disease: May Present as acute/subacute liver failure.Acute or reactivation of viral hepatitis is the most predominant cause.
  • Type B ACLF: Patients with previous compensated cirrhosis
  •  Type C ACLF: Patients with previous decompensated cirrhosis



  • Grading of ACLF (According to EASL-CLIF definition)
  • Grade1: ACLF with single organ failure
  • Grade2: ACLF with 2 organ failure
  • Grade3: ACLF with 3 or more organ failure

  •                            Management of ACLF:


  •                    General management:
  • 1. Organ support
  • 2. Treatment of associated complications
  • 3. Early identification and treatment of precipitating factors
  •                                • Bacterial infection
  •                                 GI bleeding
  •                                 Alcoholism
  •                                • Drug Toxicity


  •                 Specific therapies:
  • 1. Liver transplantation
  •             – All patients admitted with ACLF should be evaluated for LT
  • 2. Liver support system
  •              – Albumin dialysis
  •              – Plasma exchange
  •              – Molecular absorbent recirculating system (MARS)
  •             – Plasma separation and absorption system (Promethus)

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