Acute-on-chronic liver failure: Controversies and consensus

Table 1 World Gastroenterological Organisation definitions of acute-on-chronic liver failure subtypes[30]

Type A-noncirrhotic	Type B-compensated cirrhosis	Type C-decompensated cirrhosis
Acute flare of noncirrhotic CLD resulting in liver failure including hepatic encephalopathy	Rapid deterioration of previously well-compensated cirrhosis after major insult such as hepatitis (drug, viral, alcoholic), infection, or surgery	Rapid deterioration in those with previous hepatic decompensation

CLD: Chronic liver disease.

Table 2 The European Association for the Study of the Liver and chronic Liver Failure Consortium grading of acute-on-chronic liver failure severity[12,25]

ACLF Grade	Criteria
No ACLF	No organ failure or; one organ failure (liver, coagulation, circulatory, respiratory) with serum creatinine < 1.5 mg/dL and no HE or single cerebral failure and serum creatinine < 1.5 mg/dL
Grade 1	Single kidney failure or single liver, coagulation, circulatory, or respiratory failure + serum creatinine 1.5-1.9 mg/dL and/or HE I-II or single cerebral failure (HE III-IV) + serum creatinine 1.5-1.9 mg/dL
Grade 2	2 organ failures
Grade 3	3 or more organ failures

HE: Hepatic encephalopathy; ACLF: Acute-on-chronic liver failure.

Table 3 Defining organ/system failure using Chronic Liver Failure-Acute-on-Chronic Liver Failure Sequential Organ Failure Assessment scoring[12]

Organ system	Parameter	Score = 1	Score = 2	Score = 3
Liver	Serum bilirubin (mg/dL)	< 6	6-12	> 12
Kidney	Serum creatinine (mg/dL)	< 2	2.0-3.5	≥ 3.5 or renal replacement therapy
Brain	West-Haven grade	0	I-II	III-IV
Coagulation	INR	< 2.0	2.0-2.5	≥ 2.5
Circulation	MAP (mmHg)	≥ 70	< 70	Vasopressors
Respiratory	PaO2/FiO2	> 300	≤ 300 and > 200	≤ 200
	OR SpO2/FiO2	> 357	> 214 and ≤ 357	≤ 214

INR: International Normalized Ratio; MAP: Mean arterial pressure, mmHg millimeters of mercury; PaO2: Partial pressure of arterial oxygen; FiO2: Fraction of inspired oxygen; SpO2: Pulse oximetric saturation.