Acute-on-Chronic Liver Failure

Acute decompensation of stable compensated or uncompensated chronic liver disease leading to additional organ failure and ↑ short term mortality. ACLF is:

• Classified by number of organ failures into:
  • Class 1
    Single organ failure, further divided into:
    • 1a: Renal failure
    • 1b: Non-kidney organ failure
  • Class 2
    Two organ failures.
  • Class 3
    Three organ failures.
• Characterised by:
  • Ascites
  • Encephalopathy
  • Gastrointestinal haemorrhage
  • Infection

Epidemiology and Risk Factors

Pathophysiology

Aetiology

Common precipitants include:

• Infection
  • Bacterial peritonitis
• Variceal haemorrhage
• Alcoholic hepatitis
  Acute onset of jaundice or ascites in a patient with chronic alcohol abuse.
• HCC
• Portal vein thrombosis

Clinical Features

Usual presentations include:

Hepatic encephalopathy is covered under Hepatic Encephalopathy.

• Encephalopathy
• Sepsis
• Renal failure
• Variceal haemorrhage

Investigations

Imaging:

• Ultrasound
  • Portal vein patency
  • Hepatic vein patency
  • Malignancy

Other:

• Ascitic tap

Diagnostic Approach and DDx

Management

• Treat concurrent hepatic encephalopathy
  Preventative measurement with lactulose and rifaximin may also apply.

Resuscitation:

Specific therapy:

• Pharmacological
• Procedural
• Physical

Supportive care:

• A
  • Intubation
    For aspiration prevention with haematemesis.
• C
  • Individualise MAP target
    Tolerate MAP 60mmHg (or lower, depending on baseline pressure).
    • Noradrenaline 1^st line
    • Vasopressin 2^nd line
• D
  • ICP control
  • Low dose sedation usually adequate
• G
  • Feeding
    Protein 1.2-2g/kg/day.
  • Correct hypoglycaemia
  • Trace element and micronutrient supplementation
• H
  • Hb >70

Cerebral oedema secondary to hyperammonaemia is less common in ACLF due to established compensatory mechanisms.

Disposition:

Marginal and Ineffective Therapies

Anaesthetic Considerations

Complications

• H
  • Coagulopathy
    
    • Patients may be prothrombotic, anti-thrombotic, or fibrinolytic
    • Assays themselves (both coagulation profiles and point-of-care testing) may not correlate with the observed clinical effect
    • Treat if bleeding or:
      • Prior to procedures
      • INR >5
        May require continuous FFP infusion in unstable patients.
      • Fibrinogen <0.8
      • Platelets <20×10⁹/L
    • Therapeutic options:
      • Vitamin K 10mg IV daily
        Very reasonable, probably ineffective in the majority of patients.
      • PCC
        Useful for factor replacement without volume load.
      • Fibrinogen
        Target >1.5g/L. Dysfibrinogenaemia is likely in chronic disease.
  • Individualisation of thromboprophylaxis

Prognosis

Key Studies

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References

1. Van Eldere A, Pirani T. Liver intensive care for the general intensivist. Anaesthesia. 2023;78(7):884-901.