Table 2.
Principles of treatment of ACLF [3]. ICA, International Club of Ascites; AKI, acute kidney injury; HRS, hepatorenal syndrome; RRT, renal replacement therapy; LT, liver transplantation; NSAID, non-steroidal anti-inflammatory drugs; MAP, mean arterial pressure; SBP, spontaneous bacterial peritonitis; LVP, large volume paracentesis; DVT deep-vein thrombosis; PaO2 FiO2 SpO2 ACLF, acute-on-chronic liver failure.
| Kidney | Circulation | Coagulation | Lung | Brain | Infections |
|---|---|---|---|---|---|
| Assess AKI severity using ICA Criteria * Taper/withdraw from diuretics and beta-blockers, withdraw from nephrotoxic drugs | Assess hemodynamic state early; consider a MAP ≥ 65 mmHg as target | Assess complete blood count and coagulation tests | Assess respiratory state by using also imaging techniques Calculate PaO2/FiO2 or SpO2/FiO2 | Assess hepatic encephalopathy using West Haven criteria. Identify and treat the underlying cause | Perform a complete work up for infection at ACLF diagnosis |
| Administer albumin (1 g/kg for 48 h) if AKI stage > 1a * to volume expansion; if HRS-AKI, administer terlipressin by continuos infusion (2 mg/24 h) and albumin (20/40 g/day) | Administer crystalloids and 5% albumin as resuscitation fluids; norephinephrine as first line vasopressor |
Administer platelets (if < 20.000 × 109/L) and fibrinogen (if <1 g/L) if invasive procedures | Administer oxygen and ventilation with lung protective strategy | Administer lactulose and enemas for hepatic encephalopathy. | Administer broad spectrum high-dose antibiotics at ACLF diagnosis and frequently re-assess therapy |
| Consider RRT as bridge to LT | Consider 20% albumin if AKI (see Kidney), SBP, LVP; consider terlipressin if additional agent needed | Consider prophylaxis for DVT in patients without severe coagulopathy | Consider intubation if risk of aspiration (West Haven grade III or IV hepatic encephalopathy) | Consider short-acting sedative agents if necessary | Consider antifungal agents if risk factors for fungal infections |
| Avoid NSAIDs | Avoid starches | Avoid fresh frozen plasma to correct INR if no bleeding | Avoid delay in intubation even if normal blood oxygen level | Avoid deep sedation and benzodiazepines | Avoid delay in antibiotics administration |
* See ref. [34].