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Acute-on-chronic liver failure: an update
  1. Ruben Hernaez1,
  2. Elsa Solà2,3,4,
  3. Richard Moreau5,6,7,8,9,
  4. Pere Ginès2,3,4
  1. 1Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas, USA
  2. 2Liver Unit, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
  3. 3Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
  4. 4Centro d'Investigaciones Biomedicas en Red, enfermedades Hepaticas y Digestivas (CIBEReHD), Barcelona, Spain
  5. 5Inserm, U1149, Centre de Recerche sur l'inflammation (CRI), Paris, France
  6. 6Faculté de Médicine, Université Paris Diderot, Paris, France
  7. 7Départment Hospitalo-Universitaire (DHU) UNITY, Service d'Hépatologie, Hôpital Beaujon, AP-HP, Clichy, France
  8. 8Laboratoire d'Excellence (Labex) Inflamex, CUE Sorbonne Paris Cité, Paris, France
  9. 9European Foundation for the Study of Chronic Liver Failure (EF-CLIF), Barcelona, Spain
  1. Correspondence to Dr Pere Ginès, Liver Unit, Hospital Clinic of Barcelona, University of Barcelona, Institut d'Investigacions Biomèdiques August Pi I Sunyer (IDIBAPS), Barcelona 08036, Spain; PGINES{at}; pgines{at}


Acute-on-chronic liver failure (ACLF) is a syndrome characterised by acute decompensation of chronic liver disease associated with organ failures and high short-term mortality. Alcohol and chronic viral hepatitis are the most common underlying liver diseases. Up to 40%–50% of the cases of ACLF have no identifiable trigger; in the remaining patients, sepsis, active alcoholism and relapse of chronic viral hepatitis are the most common reported precipitating factors. An excessive systemic inflammatory response seems to play a crucial role in the development of ACLF. Using a liver-adapted sequential organ assessment failure score, it is possible to triage and prognosticate the outcome of patients with ACLF. The course of ACLF is dynamic and changes over the course of hospital admission. Most of the patients will have a clear prognosis between day 3 and 7 of hospital admission and clinical decisions such as evaluation for liver transplant or discussion over goals of care could be tailored using clinical scores. Bioartificial liver support systems, granulocyte-colony stimulating factors or stem-cell transplant are in the horizon of medical care of this patient population; however, data are too premature to implement them as standard of care.


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  • RM and PG are joint senior authors.

  • Contributors RH, PG, ES and RM wrote and contributed to this paper equally. Final review and approval was given by all authors.

  • Funding Some of the work mentioned has been supported by grants awarded to PG (PI12/00330), integrated in the Plan Nacional I+D+I and co-funded by ISCIII-Subdirección General de Evaluación and European Regional Development Fund FEDER; Agencia de Gestió d'Ajuts Universitaris I de Recerca (AGAUR) 2014/SGR 708; PG is a recipient of an ICREA Academia Award. Acknowledgement is made to the LiverHope project, part of the EC H2020-SC1-2016-RTD programme, number: 731875.

  • Competing interests PG declares that he has received research funding from Ferring Pharmaceuticals, Grifols S.A. and Sequana Medical. He has participated on Advisory Boards for Ferring Pharmaceuticals, Promethera and Novartis.

  • Provenance and peer review Commissioned; externally peer reviewed.

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