Acute-on-Chronic Liver Failure
Official guideline from the American College of Gastroenterology.
Diagnosis
Coagulation Failure
In patients with cirrhosis as compared to noncirrhotic populations, we suggest there is an increased risk of VTE.
Conditional recommendation
Low quality evidence
Kidney Failure
In patients with cirrhosis, we suggest against the use of biomarkers to predict the development of renal failure.
Conditional recommendation
Very low quality evidence
Management
Assessment
In hospitalized decompensated cirrhotic patients, we recommend assessment for infection because infection is associated with the development of ACLF and increased mortality.
Strong recommendation
Moderate quality evidence
In patients with cirrhosis who require invasive procedures, we recommend the use of TEG or ROTEM, compared with INR, to more accurately assess transfusion needs.
Conditional recommendation
Moderate quality evidence
Brain Failure
In hospitalized patients with ACLF, we suggest the use of short-acting dexmedetomidine for sedation as compared to other available agents to shorten time to extubation.
Conditional recommendation
Very low quality evidence
In patients with cirrhosis and ACLF who continue to require mechanical ventilation because of brain conditions or respiratory failure despite optimal therapy, we suggest against listing for LT to improve mortality.
Conditional recommendation
Very low quality evidence
Coagulation Failure
In patients with ACLF and altered coagulation parameters, we suggest against transfusion in the absence of bleeding or a planned procedure.
Conditional recommendation
Low quality evidence
In patients with cirrhosis and ACLF, we suggest against INR as a means to measure coagulation risk.
Conditional recommendation
Very low quality evidence
Kidney Failure
In patients with cirrhosis and SBP, we recommend albumin in addition to antibiotics to prevent AKI and subsequent organ failures.
Strong recommendation
High quality evidence
In patients with cirrhosis and infections other than SBP, we recommend against albumin to improve renal function or mortality.
Strong recommendation
High quality evidence
In patients with cirrhosis and elevated baseline sCr who are admitted to the hospital, we suggest monitoring renal function closely because elevated baseline creatinine is associated with worse renal outcomes and 30-day survival (but no data that closer monitoring improves these outcomes).
Conditional recommendation
Very low quality evidence
Management
In hospitalized patients with cirrhosis, we recommend against daily infusion of albumin to maintain albumin >3 g/dL to improve mortality, prevention of renal dysfunction, or infection.
Strong recommendation
Moderate quality evidence
In patients with cirrhosis and ACLF, we suggest against the use of G-CSF to improve mortality.
Conditional recommendation
Very low quality evidence
In patients with end-stage liver disease admitted to the hospital, we suggest early goals of care discussion and if appropriate, referral to palliative care to improve resource utilization.
Conditional recommendation
Very low quality evidence
In patients with cirrhosis who are hospitalized, we suggest against the routine use of parenteral nutrition, enteral nutrition, or oral supplements to improve mortality.
Respiratory Failure
In ventilated patients with cirrhosis, we suggest against prophylactic antibiotics to reduce mortality or duration of mechanical ventilation.
Conditional recommendation
Very low quality evidence
Transplant
In patients with cirrhosis and ACLF who continue to require mechanical ventilation because of ARDS or brain-related conditions despite optimal therapy, we suggest against listing for LT to improve mortality.
Conditional recommendation
Very low quality evidence
Treatment
Alcohol Associated Hepatitis
In patients with severe alcohol-associated hepatitis (MDF ≥ 32; MELD score > 20) in the absence of contraindications, we recommend the use of prednisolone or prednisone (40 mg/d) orally to improve 28-day mortality.
Strong recommendation
Moderate quality evidence
In patients with severe alcohol-associated hepatitis (MDF ≥ 32; MELD score > 20), we suggest against the use of pentoxifylline to improve 28-day mortality.
Conditional recommendation
Very low quality evidence
Infections
In patients with cirrhosis with a history of SBP, we suggest use of antibiotics for secondary SBP prophylaxis to prevent recurrent SBP (unable to comment on specific antibiotic choice).
Conditional recommendation
Low quality evidence
In patients with cirrhosis in need of primary SBP prophylaxis, we suggest daily prophylactic antibiotics, although no one specific regimen is superior to another, to prevent SBP.
Conditional recommendation
Low quality evidence
In patients with cirrhosis and suspected infection, we suggest early treatment with antibiotics to improve survival.
Conditional recommendation
Very low quality evidence
In hospitalized patients with ACLF because of a bacterial infection who have not responded to antibiotic therapy, we suggest suspicion of a MDR organism or fungal infection to improve detection.
Conditional recommendation
Very low quality evidence
In patients with cirrhosis, we suggest avoiding PPI unless there is a clear indication because PPI increases the risk of infection.
Conditional recommendation
Very low quality evidence
Kidney Failure
In hospitalized patients with cirrhosis and HRS-AKI without high grade of ACLF or major cardiopulmonary or vascular disease, we suggest terlipressin to improve renal function.
Conditional recommendation
Moderate quality evidence
In patients with cirrhosis and stages 2 and 3 AKI, we suggest IV albumin and vasoconstrictors as compared to albumin alone, to improve creatinine.
Conditional recommendation
Low quality evidence
In hospitalized patients with cirrhosis and HRS-AKI without high grade of ACLF or major cardiopulmonary or vascular disease, we suggest norepinephrine to improve renal function.
Conditional recommendation
Low quality evidence
What do the icons mean?
How strong is the ACG's recommendation?
Strong recommendation
Intervention's desirable effects clearly outweigh undesirable effects.Conditional recommendation
Uncertainty in tradeoffs between desirable & undesirable effects of intervention.High quality evidence
Further research unlikely to change guideline authors' confidence in estimate of effect.Moderate quality evidence
Further research likely to impact confidence in estimate of effect.Low quality evidence
Further research expected to have important impact in confidence in estimate of effect.Very low quality evidence
Any estimate of effect is very uncertain.Literature
