Acute-on-chronic liver failure: clinical course and liver transplantation

ABSTRACT

Introduction

Acute-on-chronic liver failure (ACLF) is a clinical syndrome characterized by intense systemic inflammatory response, multiple-organ failures, and high short-term mortality in patients with chronic liver disease. ACLF is dynamic and heterogeneous, and the prognosis is closely related to the clinical course. Currently, liver transplantation (LT) remains the only potential curative treatment that improves survival of ACLF patients.

Areas covered

In this review, we summarize the dynamic clinical course of ACLF and the relationship between the clinical course and the post-LT prognosis, especially the factors affecting the mortality after LT in severe ACLF patients and explore the optimal choice of LT therapy for ACLF patients, both to benefit patients the most and to avoid futile therapy.

Expert opinion

ACLF is a dynamic disease with varying clinical phenotypes, and the global burden is high. Early identification of the clinical course is important to assess the prognosis and guide the treatment. The contradiction between shortage of liver donors and the large number of recipients makes it necessary for us to strictly screen out the recipients and identify patients who really need LT to save liver sources.

KEYWORDS:

• Acute-on-chronic liver failure
• liver transplant
• organ allocation
• APASL ACLF research consortium
• model for end-stage liver disease

Article highlights

• ACLF is a dynamic clinical syndrome with high short-term mortality, leading to multiple-organ failures.

• There is no global standard definition on ACLF, and the main differences between various definitions are the underlying state of liver disease, diagnosis criteria, and the precipitating causes.

• The prognosis of ACLF correlates better with clinical course than with initial ACLF grade. Assessment of ACLF at 3–7 days after diagnosis accurately predicts survival of patients and provides a good tool to define the need and timing of LT.

• Dynamic changes of clinical course of ACLF prior to transplantation significantly affects the post-LT survival. Recovery from at least one previously failed organ system between diagnosis of ACLF and LT was associated with excellent posttransplant survival rates.

• A rapid decision process is required as the transplantation window is short for patients with multiple-organ failures.

• Patients with ACLF are disadvantaged by MELD-based organ allocation policy and CLIF-C ACLF is a more accurate score system for liver allocation. New liver allocation policies should be developed to make LT more equitable and fairer in the future.

• OFs based scores are the best way to evaluate the prognosis of ACLF patients, especially in severe patients with multiple-organ failures.

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Declaration of interests

The authors have no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties.

Reviewer disclosures

Peer reviewers on this manuscript have no relevant financial or other relationships to disclose.

Additional information

Funding

This paper was funded by the Construction Project of High-level Technology Talents in Public Health (Discipline leader −01-12), Beijing Hospitals Authority’s Ascent Plan (DFL20221501).