Arroyo V, Moreau R, Jalan R. Acute-on-chronic liver failure. Hassan EA, Abd El-Rehim AS, Hassany SM, et al. Acute liver failure is a rare disease defined by jaundice, coagulopathy, and hepatic encephalopathy. The factors that predict mortality after the development of ACLF include liver surgery, alkaline phosphatase with a cutoff of 164 IU/L, and an MELD score with a cutoff of 10. Pose E, Napoleone L, Amin A, et al. Organ failures include liver, kidney, brain, respiratory system, circulation, and coagulation, and they are assessed by the CLIF-consortium organ failures score (, North American Consortium for the Study of End-Stage Liver Disease (NACSELD) defines ACLF by the presence of at least 2 severe extrahepatic organ failures including shock, grade III/IV HE, renal replacement therapy (RRT), or mechanical ventilation (. In patients with cirrhosis, we suggest avoiding PPI unless there is a clear indication, such as symptomatic gastroesophageal reflux or healing of erosive esophagitis or an ulcer, because PPI use increases the risk of infection (very low quality, conditional recommendation). 17. Factors associated with survival of patients with severe acute-on-chronic liver failure before and after liver transplantation. PREVALENCE of non-alcoholic fatty liver disease (NAFLD) has increased in females who are pregnant, according to new data. The Fractionated Plasma Separation and Adsorption (Prometheus) liver support system works through a slightly different principle. Therefore, all nonelectively admitted patients with cirrhosis should be evaluated for infection with prompt initiation of antibiotics when infection is suspected to prevent ACLF development. Key concepts are statements that the GRADE process has not been applied to and often include definitions and epidemiological statements rather than diagnostic or management recommendations. Vuyyuru SK, Singh AD, Gamanagatti SR, et al. Expert Rev Gastroenterol Hepatol 2018;12:34150. 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 (very low quality, conditional recommendation). No study has ever documented superiority of one regimen over another. At this time, it is unclear whether alcohol-related ACLF is a specific form of alcohol-associated liver disease or represents a later stage of severe AAH. Most patients developed grade 1 ACLF, with the most common organ failure being renal failure defined as an sCr of >2.0 mg/dL. However, it is not anticipated that the routine use of antibiotics will be associated with a lower risk of VAP. 64. Hepatitis Bassociated ACLF therefore is much more common in Asia than in Western countries, contributing to 15% of cases of ACLF in Asian Pacific countries (142,143). Singer M, Deutschman CS, Seymour CW, et al. BP, blood pressure; GI, gastrointestinal; HE, hepatic encephalopathy; IV, intravenous; NG, nasogastric; PO, per oral. Hepatology 2017;66:146473. This study also evaluated the ACLF rates in other non-ERCP interventions among cirrhotic patients. Bacterial infections in end-stage liver disease: Current challenges and future directions. Hemodynamic studies in acute-on-chronic liver failure. 12. In hospitalized decompensated cirrhotic patients, we recommend assessment for infection because infection is associated with the development of ACLF and increased mortality (moderate quality, strong evidence). A retrospective analysis of the United Network for Organ Sharing database showed that EASL-CLIF ACLF-3 patients did well after transplant, whereas those on mechanical ventilation did not. For example, PPIs are needed to heal gastrointestinal ulcers and erosive esophagitis and treat gastroesophageal reflux not responsive to H2 blockers (115). The impact of albumin use on resolution of hyponatremia in hospitalized patients with cirrhosis. Nonselective beta-blockers (NSBB) may decrease bacterial translocation, but patients with ACLF have difficulty tolerating clinically relevant doses. A commonly used cutoff to define acute liver failure is an illness duration of <26 weeks. In a multicenter French and Belgian study, the combination of prednisone and pentoxifylline has not been found to be superior to prednisone alone (128). Am J Gastroenterol 2020;115(12):202635. In patients with cirrhosis without ACLF, a rebalancing in coagulation occurs; however, in specific circumstances, hypercoagulability can be found (81,82). 99. Patients with ACLF are best managed in the intensive care unit (ICU), and some may benefit from early liver transplantation. 26. Xue R, Meng Q, Dong J, et al. These guidelines indicate the preferred approach to the management of patients with acute-on-chronic liver failure and represent the official practice recommendations of the American College of Gastroenterology. This is particularly true in areas of low and turbulent flow, such as the portal venous system. However, no details about the ACLF episodes related to these interventions are provided. Bajaj JS, Lauridsen M, Tapper EB, et al. Granulocyte colonystimulating factor mobilizes CD34+ cells and improves survival of patients with acute-on-chronic liver failure. 19. 14. J Translational Med 2018;16:126. Bacterial infections are a common trigger of ACLF in patients with viral hepatitis, which should be monitored for and treated promptly. Hepatology 2015;62:23242. In the intention-to-treat analysis, 6-month survival was not different between the pentoxifylline-prednisolone and placebo-prednisolone groups (69.9% [95% CI 62.1%77.7%] vs 69.2% [95% CI 61.4%76.9%], P = 0.91). Table 1 is a summary of recommendations, whereas Table 2 shows the key concept statements. Granulocyte-colony stimulating factor for acute-on-chronic liver failure: Systematic review and meta-analysis. 161. In highly selected patients with severe AAH not responding to optimal medical therapy and supportive measures, LT may be considered (135,136). Gastroenterology 2015;149:398406.e8; quiz e167. The impact of HBV flare on the outcome of HBV-related decompensated cirrhosis patients with bacterial infection. If precipitating events, such as viral hepatitis, drug-induced liver injury, and alcohol-related hepatitis, are superimposed on chronic liver disease, the result may be hepatic and extrahepatic organ failure, termed acute-on-chronic liver failure or ACLF. Post-traumatic stress in the intensive care unit. Predictors of poor outcomes after LT have included mechanical ventilation, higher donor risk index, older age, and LT > 30 days after listing (200).