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    Acute-on-Chronic Liver Failure (beta)

    Official guideline from the American College of Gastroenterology.

    Strength
    Strong recommendation
    Conditional recommendation
    Evidence
    High quality evidence
    Moderate quality evidence
    Low quality evidence
    Very low quality evidence

    Diagnosis

    Coagulation Failure
    1. In patients with cirrhosis as compared to noncirrhotic populations, we suggest there is an increased risk of VTE.
    Kidney Failure
    1. In patients with cirrhosis, we suggest against the use of biomarkers to predict the development of renal failure.

    Management

    Assessment
    1. In hospitalized decompensated cirrhotic patients, we recommend assessment for infection because infection is associated with the development of ACLF and increased mortality.
    2. 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.
    Brain Failure
    1. 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.
    2. 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.
    Coagulation Failure
    1. In patients with ACLF and altered coagulation parameters, we suggest against transfusion in the absence of bleeding or a planned procedure.
    2. In patients with cirrhosis and ACLF, we suggest against INR as a means to measure coagulation risk.
    Kidney Failure
    1. In patients with cirrhosis and SBP, we recommend albumin in addition to antibiotics to prevent AKI and subsequent organ failures.
    2. In patients with cirrhosis and infections other than SBP, we recommend against albumin to improve renal function or mortality.
    3. 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).
    Management
    1. 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.
    2. In patients with cirrhosis and ACLF, we suggest against the use of G-CSF to improve mortality.
    3. 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.
    4. 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
    1. In ventilated patients with cirrhosis, we suggest against prophylactic antibiotics to reduce mortality or duration of mechanical ventilation.
    Transplant
    1. 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.

    Treatment

    Alcohol Associated Hepatitis
    1. 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.
    2. In patients with severe alcohol-associated hepatitis (MDF ≥ 32; MELD score > 20), we suggest against the use of pentoxifylline to improve 28-day mortality.
    Infections
    1. 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).
    2. 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.
    3. In patients with cirrhosis and suspected infection, we suggest early treatment with antibiotics to improve survival.
    4. 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.
    5. In patients with cirrhosis, we suggest avoiding PPI unless there is a clear indication because PPI increases the risk of infection.
    Kidney Failure
    1. 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.
    2. In patients with cirrhosis and stages 2 and 3 AKI, we suggest IV albumin and vasoconstrictors as compared to albumin alone, to improve creatinine.
    3. 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.
    What do the icons mean?  
    Research PaperBajaj JS, O’Leary JG, Lai JC, et al. Acute-on-chronic liver failure clinical guidelines. Am J Gastroenterol. 2022;117(2):225-252.