Decompensated liver cirrhosis and acute-on-chronic liver failure

Patients with liver cirrhosis who require treatment in an intensive care unit (ICU) have a high mortality rate. It is important to distinguish decompensated liver cirrhosis with typical disease-associated complications (e.g., esophageal variceal bleeding, hepatic encephalopathy, hepatorenal syndrome or ascites) from acute-on-chronic liver failure (ACLF), in which single or multiple organ failure rapidly develops on top of a pre-existing decompensated chronic liver disease. Organ failure is clearly defined by the CLIF-C organ failure (OF) score. In both decompensated cirrhosis and ACLF, structured ICU management that includes the treatment of precipitating events (e.g., bleeding, infections volume depletion, medication) and concomitant organ failure (e.g., renal failure, encephalopathy) is essential. Of particular importance is rapid and adequate (antibiotic and antifungal) infectious therapy, and clear treatment algorithms exist for cirrhosis-associated complications such as renal failure/hepatorenal syndrome, hepatic encephalopathy, ascites or variceal bleeding. The possibility of liver transplantation should always be part of an interdisciplinary discussion about individual therapeutic strategies. New treatment approaches for ACLF address mechanisms of inflammation, immune response, and regeneration in clinical trials.