What are the guideline sources, guidelines and references for Acute-on-chronic liver failure ?
Guideline sources The following summarized guidelines for the evaluation and management of acute-on-chronic liver failure (ACLF) are prepared by our editorial team based on guidelines from the Society of Critical Care Medicine (SCCM 2023; 2020), the American College of Gastroenterology (ACG 2022), and the European Association for the Study of the Liver (EASL 2018). 1 2 3 4 Guidelines 1. Screening and diagnosis Diagnosis: establish the diagnosis of ACLF in patients with cirrhosis and acute decompensation (defined as the acute development or worsening of ascites, overt encephalopathy, gastrointestinal hemorrhage, nonobstructive jaundice, and/or bacterial infections) when organ failures involving high short-term mortality develop. B Show 2 more https://web.pathway.md/diseases/recv7yYarFkEPlvTk 1/6 6/23/23, 2:08 AM Acute-on-chronic liver failure Pathway 2. Diagnostic investigations Medication review: screen patients with ACLF for drug-induced causes of liver failure. Discontinue drugs proven or highly suspected to be the cause of ACLF. E Viscoelastic testing: As per ACG 2022 guidelines, obtain thromboelastography or rotational thromboelastography rather than INR to more accurately assess transfusion needs in patients with cirrhosis requiring invasive procedures. B As per SCCM 2020 guidelines: Consider obtaining viscoelastic testing (thromboelastography/rotational thromboelastography) over measuring INR, platelet, and fibrinogen in critically ill patients with ACLF. C Obtain viscoelastic testing (thromboelastography/rotational thromboelastography) over measuring INR, platelet, and fibrinogen in critically ill patients with ACLF undergoing procedures. B Coagulation studies: avoid obtaining INR as a means to measure coagulation risk in patients with cirrhosis and ACLF. D 3. Respiratory support Supplemental oxygen: Provide supportive care with supplemental oxygen in the management of patients with hepatopulmonary syndrome, pending possible liver transplantation. E Consider using high-flow nasal cannula over noninvasive ventilation in hypoxic critically ill patients with ACLF. C Mechanical ventilation: Consider using a low tidal volume strategy in patients with ACLF and ARDS. C Avoid using high PEEP in patients with ACLF and ARDS. D 4. Medical management General principles, goals of care: As per ACG 2022 guidelines, consider discussing early goals of care with patients with end- stage liver disease admitted to the hospital and if appropriate, refer to palliative care to improve resource utilization. C As per SCCM 2020 guidelines, consider targeting a mean arterial pressure of 65 mmHg in patients with ACLF, with concomitant assessment of perfusion. C Show 2 more General principles (supportive care): recognize that there is no specific therapy for ACLF aside from antiviral therapy in patients with ACLF due to reactivation of HBV infection. B https://web.pathway.md/diseases/recv7yYarFkEPlvTk 2/6 6/23/23, 2:08 AM Acute-on-chronic liver failure Pathway Show 4 more General principles, precautions: As per ACG 2022 guidelines, avoid using PPIs in patients with cirrhosis unless there is a clear indication because PPIs increase the risk of infection. D As per SCCM 2020 guidelines: Adjust the doses of medications undergoing hepatic metabolism based on the patient's residual hepatic function. Consult a clinical pharmacist when available. E Avoid using eltrombopag before surgery/invasive procedures in patients with ACLF with thrombocytopenia. D Fluid resuscitation: Do not use hydroxyethyl starch for initial fluid resuscitation of patients with ACLF. D Avoid using gelatin solutions for initial fluid resuscitation of patients with ACLF. D Albumin: As per ACG 2022 guidelines, avoid administering daily infusion of albumin to maintain albumin > 3 g/dL to improve mortality, prevent renal dysfunction or infection in hospitalized patients with cirrhosis. D As per SCCM 2020 guidelines, consider administering albumin over other fluids for resuscitation of patients with ACLF, especially if serum albumin is < 3 mg/dL. C Vasopressors: administer vasopressors in critically ill patients with ACLF developing hepatorenal syndrome. B Show 2 more Thromboprophylaxis: As per ACG 2022 guidelines, recognize that there is an increased risk of VTE in patients with cirrhosis as compared to non-cirrhotic populations. B As per SCCM 2020 guidelines, consider administering LMWH over offering pneumatic compression stockings for venous thromboprophylaxis in hospitalized patients with ACLF. C Antibiotic prophylaxis: As per SCCM 2023 guidelines, administer antibiotic prophylaxis in critically ill patients with ACLF and any type of upper gastrointestinal bleeding. B As per ACG 2022 guidelines, consider administering antibiotic prophylaxis for secondary SBP to prevent recurrence in patients with cirrhosis with a history of SBP. C Show 2 more Granulocyte colony-stimulating factor: As per ACG 2022 guidelines, avoid administering G-CSF to improve mortality in patients with cirrhosis and ACLF. D As per EASL 2018 guidelines, do not use G-CSF in patients with ACLF. D Antiviral therapy: initiate nucleoside analogs (tenofovir, entecavir) as early as possible in patients with ACLF due to HBV infection. A https://web.pathway.md/diseases/recv7yYarFkEPlvTk 3/6 6/23/23, 2:08 AM Acute-on-chronic liver failure Pathway Sedation: consider administering short-acting dexmedetomidine for sedation to shorten time to extubation in hospitalized patients with ACLF. C Management of portal hypertension: perform upper gastrointestinal endoscopy within 12 hours of presentation in critically ill patients with ACLF and portal hypertensive bleeding (known or suspected). E Show 4 more Management of portopulmonary hypertension: consider treating portopulmonary hypertension with agents approved for pulmonary arterial hypertension in patients with mean pulmonary artery pressure > 35 mmHg. C Management of vascular complications: consider administering LMWH or vitamin K antagonists over offering conservative management in patients with portal venous thrombosis or pulmonary embolus. C Management of infections: obtain assessment for infection in hospitalized patients with decompensated cirrhosis because infection is associated with the development of ACLF and increased mortality. B Show 2 more Management of spontaneous bacterial peritonitis: administer albumin in critically ill patients with ACLF and SBP. B Show 3 more Management of septic shock: As per SCCM 2023 guidelines, consider initiating appropriate antibiotics as soon as possible after recognition and within 1 hour of shock onset in critically ill patients with ACLF and septic shock. C As per SCCM 2020 guidelines, consider administering stress-dose corticosteroids for the management of septic shock in patients with ACLF. C Management of hepatic encephalopathy: consider administering nonabsorbable disaccharides in critically ill patients with ACLF and overt hepatic encephalopathy. C Show 4 more Management of acute kidney injury: As per ACG 2022 guidelines, avoid obtaining biomarkers to predict the development of renal failure in patients with cirrhosis. D Show 4 more As per SCCM 2020 guidelines, consider performing early RRT in patients with ALF and AKI. C 5. Inpatient care Hemodynamic monitoring: Consider placing an arterial catheter for BP monitoring in patients with ACLF and shock. C https://web.pathway.md/diseases/recv7yYarFkEPlvTk 4/6 6/23/23, 2:08 AM Acute-on-chronic liver failure Pathway Consider obtaining invasive hemodynamic monitoring to guide therapy in patients with ACLF and clinically impaired perfusion. C 6. Nonpharmacologic interventions Nutrition: As per ACG 2022 guidelines, avoid administering routine parenteral nutrition, enteral nutrition or oral supplements to improve mortality in hospitalized patients with cirrhosis. As per SCCM 2020 guidelines, avoid using a low protein goal in patients with ACLF. Consider targeting protein goals comparable to critically ill patients without liver failure (such as 1.2-2.0 g protein/kg dry or ideal body weight per day). D Show 2 more 7. Therapeutic procedures Blood transfusion: avoid administering transfusions in the absence of bleeding or a planned procedure in patients with ACLF and altered coagulation parameters. D Large volume paracentesis: Avoid performing large-volume paracentesis in critically ill patients with ACLF and SBP. D Perform large-volume paracentesis with measurement of intra-abdominal pressure in critically ill patients with ACLF with tense ascites and intra-abdominal hypertension or hemodynamic, renal, or respiratory compromise. E Pleurodesis: place a chest tube with an attempt to pleurodesis for hepatic hydrothorax in patients unfit for TIPS or as a palliative intent. E Extracorporeal liver support: consider initiating extracorporeal liver support or standard medical therapy in critically ill patients with ACLF. C 8. Perioperative care Peri-transplant management: consider administering balanced (or normochloremic) crystalloid solution over normal (hyperchloremic) saline for peri-transplant fluid replacement in liver transplant recipients. C Show 4 more 9. Surgical interventions Liver transplantation: As per ACG 2022 guidelines, avoid listing for liver transplant patients with cirrhosis and ACLF still requiring mechanical ventilation because of adult respiratory distress syndrome or brain- related conditions despite optimal therapy. D https://web.pathway.md/diseases/recv7yYarFkEPlvTk 5/6 6/23/23, 2:08 AM Acute-on-chronic liver failure Pathway As per EASL 2018 guidelines, refer patients with ACLF to liver transplant centers early for immediate evaluation. B 10. Specific circumstances Patients with alcohol-associated hepatitis: Administer prednisolone or prednisone (40 mg/day) PO to improve 28-day mortality in patients with severe alcohol-associated hepatitis (MDF 32; MELD score > 20) in the absence of contraindications. B Avoid using pentoxifylline to improve 28-day mortality in patients with severe alcohol-associated hepatitis (MDF 32; MELD score > 20). D References 1. Jasmohan S Bajaj, Jacqueline G O'Leary, Jennifer C Lai et al. Acute-on-Chronic Liver Failure Clinical Guidelines. Am J Gastroenterol. 2022 Jan 10. Open 2. Rahul Nanchal, Ram Subramanian, Waleed Alhazzani et al. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations. Crit Care Med. 2023 May 1;51 5 657 676. Open 3. European Association for the Study of the Liver. EASL Clinical Practice Guidelines for the management of patients with decompensated cirrhosis. J Hepatol. 2018 Aug;69 2 406 460. Open 4. Rahul Nanchal, Ram Subramanian, Constantine J Karvellas et al. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU Cardiovascular, Endocrine, Hematologic, Pulmonary and Renal Considerations: Executive Summary. Crit Care Med. 2020 Mar;48 3 415 419. Open https://web.pathway.md/diseases/recv7yYarFkEPlvTk 6/6