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Intensive care management of acute-on-chronic liver failure

  • Narrative Review
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Abstract

Acute-on-chronic liver failure (ACLF) is a clinical syndrome defined by an acute deterioration of the liver function associated with extrahepatic organ failures requiring intensive care support and associated with a high short-term mortality. ACLF has emerged as a major cause of mortality in patients with cirrhosis and chronic liver disease. ACLF has a unique pathophysiology in which systemic inflammation plays a key role; this provides the basis of novel therapies, several of which are now in clinical trials. Intensive care unit (ICU) therapy parallels that applied in the general ICU population in some organ failures but has peculiar differential characteristics in others. Critical care management strategies and the option of liver transplantation (LT) should be balanced with futility considerations in those with a poor prognosis. Nowadays, LT is the only life-saving treatment that can radically improve the long-term prognosis of patients with ACLF. This narrative review will provide insights on the current understanding of ACLF with emphasis on intensive care management.

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Author notes

  1. Rajiv Jalan, Julia Wendon and Marco Carbone are joint senior authors.

Authors and Affiliations

  1. Hepatology and Gastroenterology Unit, ASST Grande Ospedale Metropolitano Niguarda, Piazza Ospedale Maggiore 3, 20162, Milan, Italy

    Giovanni Perricone

  2. Hôpitaux Universitaires de Strasbourg, 67000, Strasbourg, France

    Thierry Artzner

  3. AP-HP Hôpital Paul Brousse, Centre Hépato-Biliaire, Inserm UMR-S 1193, Université Paris-Saclay, Villejuif, France

    Eleonora De Martin

  4. Liver Failure Group, Institute for Liver and Digestive Health, University College London, Royal Free Campus, London, UK

    Rajiv Jalan

  5. European Foundation for the Study of Chronic Liver Failure, Barcelona, Spain

    Rajiv Jalan

  6. Liver Intensive Therapy Unit, Division of Inflammation Biology, King’s College London, London, UK

    Julia Wendon

  7. Division of Gastroenterology, Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy

    Marco Carbone

  8. European Reference Network On Hepatological Diseases (ERN RARE-LIVER), Fondazione IRCCS San Gerardo dei Tintori, Monza, Italy

    Marco Carbone

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  1. Giovanni Perricone
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  2. Thierry Artzner
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  3. Eleonora De Martin
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  4. Rajiv Jalan
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  5. Julia Wendon
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  6. Marco Carbone
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Corresponding author

Correspondence to Giovanni Perricone.

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Conflicts of interest

GP, TA, EDM, JW and MC do not have conflicts of interest related to this manuscript. RJ is the inventor of OPA, which has been patented by UCL and licensed to Mallinckrodt Pharma. He is also the founder of Yaqrit Discovery, Hepyx Limited (spin out companies from University College London), and Cyberliver. He has research collaborations with Yaqrit Discovery.

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Perricone, G., Artzner, T., De Martin, E. et al. Intensive care management of acute-on-chronic liver failure. Intensive Care Med 49, 903–921 (2023). https://doi.org/10.1007/s00134-023-07149-x

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