The liver, an organ in the upper right abdomen, performs many essential functions. It filters blood from the digestive system, detoxifies chemicals, and metabolizes drugs. While the liver can regenerate, lifestyle and environmental factors can cause significant harm. Prolonged damage can lead to a decline in its capacity.
Understanding Acute on Chronic Liver Failure
Acute on chronic liver failure (ACLF) is a sudden and severe worsening of liver function in individuals with chronic liver disease. This condition involves rapid deterioration, often leading to the failure of one or more organs beyond the liver, and carries a high short-term mortality. ACLF is distinct from acute liver failure (no prior liver disease) and stable chronic liver disease. While chronic liver disease progresses gradually, ACLF involves an abrupt decompensation.
ACLF is a complex syndrome with varying definitions across global medical societies, though all agree on its severe nature and poor outcomes. The EASL-CLIF consortium defines ACLF by the onset of one or more organ failures in patients with underlying chronic liver disease experiencing acute hepatic decompensation. This condition often progresses rapidly, with increased short-term mortality.
Causes and Development
ACLF develops when an acute precipitating event occurs in those with pre-existing chronic liver disease. Common underlying chronic conditions include cirrhosis caused by prolonged alcohol consumption, chronic viral hepatitis (Hepatitis B or C), non-alcoholic fatty liver disease (now known as metabolic dysfunction-associated steatotic liver disease or MASLD), and autoimmune liver diseases. These long-standing conditions gradually damage the liver, often leading to fibrosis and ultimately cirrhosis.
The acute “triggers” that can lead to sudden decompensation are diverse. Bacterial infections are a common precipitating factor, often spontaneous bacterial peritonitis. Other triggers include acute alcohol-associated hepatitis, drug-induced liver injury, gastrointestinal bleeding, and acute viral hepatitis superinfection. In many cases, no clear precipitating event is identified.
Recognizing Symptoms and Diagnosis
Recognizing the signs of ACLF is important, as early intervention can improve outcomes. Symptoms in those developing ACLF include jaundice (yellowing of the skin and eyes), fluid accumulation in the abdomen (ascites), and hepatic encephalopathy, causing confusion or altered mental status.
Other indications of ACLF include kidney dysfunction and an increased susceptibility to infections. Diagnosis involves a combination of clinical assessment and laboratory tests. Blood tests evaluate liver function, assess clotting ability, and check for signs of kidney injury. Imaging studies may also be performed to assess the extent of liver damage, identify fluid buildup, or detect potential precipitating causes. The assessment also includes evaluating the presence and severity of organ failures using established scoring systems.
Treatment Approaches
Managing ACLF requires immediate medical intervention, often in an intensive care unit (ICU) setting, to stabilize the patient and address organ failures. Identify and treat the acute trigger. For example, bacterial infections are managed with broad-spectrum antibiotics, while acute alcohol-associated hepatitis may require specific therapies. Antiviral medications are initiated for acute hepatitis B or C reactivation.
Supportive care is a key part of ACLF treatment, focusing on managing complications and providing organ support. This includes IV fluids and nutritional support. Diuretics may be used to manage ascites, while lactulose or rifaximin can help reduce ammonia levels and improve hepatic encephalopathy. For kidney failure, dialysis may be necessary.
Patients with severe hepatic encephalopathy may require intubation for airway protection. Vasopressor medications are used to maintain adequate blood pressure and ensure proper blood flow to organs. Blood products may be transfused to address bleeding complications due to impaired clotting. For eligible patients, liver transplantation remains the definitive treatment for ACLF, offering a chance for long-term survival. Early referral to a transplant center is important to assess candidacy.
Prognosis and Long-Term Outlook
ACLF is a severe condition with high mortality rates, particularly in cases involving multiple organ failures. Prognosis varies significantly, influenced by the number and type of organ failures, underlying chronic liver disease, and treatment response.
Infections as a precipitating factor are associated with poorer outcomes. While liver transplantation offers the only definitive cure, its use is challenging due to donor scarcity and the patient’s critical condition. After recovery, ongoing management of chronic liver disease is important to prevent recurrence and improve long-term quality of life. This includes strict alcohol abstinence, avoiding hepatotoxic medications, and hepatitis A and B vaccinations.