title: Management of Acute-on-Chronic Liver Failure.
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.
authors.affiliation: Hepatology and Liver Intensive Care, Hospital Beaujon, Clichy, University Paris VII Diderot, Paris and Département Hospitalo-Universitaire UNITY, Clichy, France.
authors.forename: Francois
authors.initials: F
authors.lastname: Durand
authors.affiliation: Division of Nephrology and Hypertension, Keck School of Medicine, University of Southern California, Los Angeles, California.
authors.forename: Mitra K
authors.initials: MK
authors.lastname: Nadim
mesh_terms: D058186:Acute Kidney Injury / Q000150:complications / Q000175:diagnosis; D065290:Acute-On-Chronic Liver Failure / Q000150:complications / Q000503:physiopathology / Q000628:therapy*; D000900:Anti-Bacterial Agents / Q000627:therapeutic use; D001778:Blood Coagulation Disorders / Q000150:complications / Q000628:therapy; D024901:Drug Resistance, Multiple, Bacterial; D005440:Fluid Therapy; D006501:Hepatic Encephalopathy / Q000150:complications / Q000628:therapy; D006530:Hepatorenal Syndrome / Q000150:complications / Q000175:diagnosis; D006801:Humans; D008103:Liver Cirrhosis / Q000150:complications / Q000401:mortality / Q000628:therapy*; D016031:Liver Transplantation; D063305:Organ Dysfunction Scores; D017582:Renal Replacement Therapy; D012720:Severity of Illness Index; D012769:Shock / Q000150:complications / Q000628:therapy; D014662:Vasoconstrictor Agents / Q000627:therapeutic use
chemical_list: D000900:Anti-Bacterial Agents; D014662:Vasoconstrictor Agents