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Semin Liver Dis 2016; 36(02): 141-152
DOI: 10.1055/s-0036-1583198
Thieme Medical Publishers 333 Seventh Avenue, New York, NY 10001, USA.

Management of Acute-on-Chronic Liver Failure

Francois Durand
1   Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, University Paris VII Diderot, Paris and Département Hospitalo-Universitaire UNITY, Clichy, France
,
Mitra K. Nadim
2   Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, California
› Author Affiliations
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Publication History

Publication Date:
12 May 2016 (online)

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Abstract

Acute-on-chronic liver failure (ACLF) is defined by the occurrence of organ failure(s) other than the liver in patients with cirrhosis. Even though mortality rates are high, there should no longer be reluctance to admit patients with ACLF in the intensive care unit. The prevalence of multidrug-resistant bacteria is high and broad spectrum antibiotics should be initiated as soon as infection is suspected. In patients with circulatory failure, the assessment of circulatory status is challenging due to the hyperkinetic state and an imbalance between the splanchnic and systemic blood volume. Acute kidney injury is common in patients with ACLF. Acute tubular necrosis should be differentiated from hepatorenal syndrome, which justifies vasoconstrictive agents. Renal replacement therapy and mechanical ventilation should be decided on clinical grounds. Recent trials on extracorporeal liver support failed to demonstrate a survival benefit. Aggressive management may serve as a bridge to transplantation provided patients are likely to survive after transplantation.

Keywords

acute kidney injury - cirrhosis - acute-on-chronic liver failure - hepatorenal syndrome - intensive care - cardiopulmonary dysfunction - infectious disease - hepatic encephalopathy