title: Acute-on-chronic liver failure.
abstract: Acute-on-chronic liver failure combines an acute deterioration in liver function in an individual with pre-existing chronic liver disease and hepatic and extrahepatic organ failures, and is associated with substantial short-term mortality. Common precipitants include bacterial and viral infections, alcoholic hepatitis, and surgery, but in more than 40% of patients, no precipitating event is identified. Systemic inflammation and susceptibility to infection are characteristic pathophysiological features. A new diagnostic score, the Chronic Liver Failure Consortium (CLIF-C) organ failure score, has been developed for classification and prognostic assessment of patients with acute-on-chronic liver failure. Disease can be reversed in many patients, and thus clinical management focuses upon the identification and treatment of the precipitant while providing multiorgan-supportive care that addresses the complex pattern of physiological disturbance in critically ill patients with liver disease. Liver transplantation is a highly effective intervention in some specific cases, but recipient identification, organ availability, timing of transplantation, and high resource use are barriers to more widespread application. Recognition of acute-on-chronic liver failure as a clinically and pathophysiologically distinct syndrome with defined diagnostic and prognostic criteria will help to encourage the development of new management pathways and interventions to address the unacceptably high mortality.
authors.affiliation: Liver Intensive Therapy Unit, King's College Hospital, London, UK. Electronic address: william.bernal@kcl.ac.uk.
authors.forename: William
authors.initials: W
authors.lastname: Bernal
authors.affiliation: Liver Failure Group, Division of Medicine, University College London, London, UK; Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK; Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK.
authors.forename: Rajiv
authors.initials: R
authors.lastname: Jalan
authors.affiliation: Histopathology Section, Institute of Liver Studies, King's College Hospital, London, UK.
authors.forename: Alberto
authors.initials: A
authors.lastname: Quaglia
authors.affiliation: Department of Hepatology, University of Edinburgh, Edinburgh, UK.
authors.forename: Kenneth
authors.initials: K
authors.lastname: Simpson
authors.affiliation: Liver Intensive Therapy Unit, King's College Hospital, London, UK.
authors.forename: Julia
authors.initials: J
authors.lastname: Wendon
authors.affiliation: Institute for Liver and Digestive Health, Division of Medicine, University College London, London, UK; Sheila Sherlock Liver Centre, Royal Free Hospital, London, UK.
authors.forename: Andrew
authors.initials: A
authors.lastname: Burroughs
mesh_terms: D065290:Acute-On-Chronic Liver Failure / Q000150:complications / Q000473:pathology / Q000503:physiopathology / Q000628:therapy; D001424:Bacterial Infections / Q000150:complications; D001778:Blood Coagulation Disorders / Q000150:complications; D001927:Brain Diseases / Q000150:complications; D002318:Cardiovascular Diseases / Q000150:complications; D006801:Humans; D016031:Liver Transplantation; D063305:Organ Dysfunction Scores; D051437:Renal Insufficiency / Q000150:complications; D012720:Severity of Illness Index