LTx for Acute-on-Chronic Liver Failure: Don’t Rush It!

Acute-on-chronic liver failure (ACLF) is a dynamic syndrome associated with very high short-term mortality. Until 2013, there was no evidence-based definition of ACLF. However, a definition was later proposed based on the results of a large prospective observational European study, called “European Association for the Study of the Liver (EASL)–Chronic Liver Failure (CLIF) Consortium Acute-onChronic Liver Failure in Cirrhosis (CANONIC)” study.

The CANONIC study also found that: Identifiable precipitating events (e.g., bacterial infection, active alcoholism) are found in only 50% of cases of ACLF. Precipitating events may be initiators of ACLF but do not drive the outcome. ACLF is associated with systemic inflammation even in patients who do not have identifiable precipitating events.

When it comes to the treatment of ACLF stage 2-3, liver transplantation (LTx) has been shown to improve the survival of patients. It has been recommended that patients who recover from ACLF should also be listed for LTx, as the rate of mortality at 6 months is 40% to 50%. However, some of the factors can lead to escalation of care or futility of care after LTx, such as:

• Standard ICU consideration: Age, comorbidities, functional/nutritional status, severity of acute illness
• Liver-specific considerations: Severity of disease, indication of admission