Key points
- ACLF is a sudden worsening on top of existing liver disease, usually set off by a trigger — not simply the slow progression of cirrhosis.
- Common triggers in India are heavy drinking, hepatitis B flares, hepatitis E infection, bacterial infections and variceal bleeding; herbal medicines are another.
- Short-term risk depends mainly on how many organs fail; it is highest when three or more are affected.
- Treatment happens in an intensive care unit, and for suitable patients a liver transplant — often from a living donor — can be life-saving if done within a narrow window.
What ACLF means
In ordinary cirrhosis, the liver declines gradually over months or years. In ACLF, the decline happens over days to weeks: jaundice deepens, clotting worsens, and fluid in the abdomen or confusion appear. Unlike acute liver failure, which strikes a previously normal liver, ACLF happens in a liver that was already damaged — sometimes damage the patient did not know about until this illness.
Doctors in Asia and Europe define ACLF slightly differently. The Asian (APASL) definition emphasises new jaundice and clotting failure followed within weeks by ascites or encephalopathy; the European (EASL-CLIF) definition focuses on the number of organs failing in a patient with cirrhosis. The practical message is the same: this is a critical illness, and the patient should be looked after in a liver unit with intensive care and transplant facilities.
What triggers ACLF
| Trigger | How it happens |
|---|---|
| Alcohol binge or severe alcoholic hepatitis | A period of heavy drinking inflames an already scarred liver. See alcohol-related liver disease. |
| Hepatitis B flare | The virus reactivates — for example after stopping antiviral tablets without advice, or during chemotherapy or steroid treatment. |
| Hepatitis E or A infection | A new viral hepatitis in someone with underlying liver disease can tip the liver into failure. |
| Bacterial infection | Infection of ascitic fluid (spontaneous bacterial peritonitis), pneumonia, urinary or skin infections. Infection is both a common trigger and a common complication. |
| Variceal bleeding | Heavy bleeding from swollen veins reduces blood flow to the liver and often brings infection with it. See vomiting blood and variceal bleeding. |
| Drugs and herbal products | Anti-TB drugs, some painkillers and herbal or indigenous medicines can injure a vulnerable liver. |
In some patients no clear trigger is found. Identifying the trigger matters because several of them — infection, hepatitis B and bleeding — can be treated directly.
Warning signs
Take the patient to hospital immediately if someone with liver disease develops:
rapidly deepening jaundice; confusion, drowsiness or unusual behaviour; vomiting blood or passing black stools; fever, shivering or abdominal pain; breathlessness; very little urine; or fast swelling of the abdomen. In a person with known liver disease, these are signs that ACLF may be developing, and hours matter.
Organ failures and what they mean for survival
The seriousness of ACLF is judged by which organs are failing and how many. Doctors monitor six systems:
- Liver — high bilirubin, rising INR.
- Kidneys — rising creatinine, falling urine output; dialysis may be needed.
- Brain — hepatic encephalopathy, from confusion to coma.
- Clotting — bleeding tendency.
- Circulation — low blood pressure needing medicines to support it.
- Lungs — low oxygen levels, sometimes needing a ventilator.
Short-term mortality in ACLF is high, and it is important to say so honestly. Published studies from large centres report that the risk of death within about a month rises steeply with the number of failing organs — from roughly one in five with a single organ failure to more than half when three or more organs fail. These are group averages; the team's daily assessment of an individual patient, and how they respond over the first week of treatment, is far more informative.
How ACLF is treated in intensive care
- 1
Find and treat the trigger
Blood, urine and ascitic fluid cultures with early antibiotics for infection; antivirals for hepatitis B; endoscopic treatment for bleeding; stopping alcohol and every non-essential medicine or herbal product.
- 2
Support failing organs
Careful fluids and albumin, medicines to support blood pressure and kidney function, dialysis, oxygen or ventilation, and treatment of encephalopathy.
- 3
Nutrition and prevention
Early feeding, including by tube if needed, prevention of hospital infections, and protection against bleeding.
- 4
Specific treatments in selected patients
Steroids may be considered for severe alcoholic hepatitis if there is no active infection. Some centres use plasma exchange in carefully selected patients; its role is still being studied.
- 5
Reassess and decide
Organ function scores are repeated at intervals — often at around day 3 to 7 — to judge whether the patient is improving, and whether a transplant is needed.
The role and timing of liver transplant
For patients who do not improve with intensive treatment, a liver transplant may be the only treatment that can save life. Published experience from large centres shows that carefully selected patients with ACLF — including some with several organ failures — can do well after transplant. The difficulty is timing: there is often a window of days to a few weeks when the patient is sick enough to need a transplant but still fit enough to survive the operation.
The window may close if infection becomes uncontrolled, if blood pressure needs escalating support, if the lungs fail severely, or if the brain is irreversibly injured. For this reason the transplant team assesses the patient at the start of the admission, not only after other treatments have failed.
Because deceased-donor organs are scarce in India, most transplants for ACLF are done as living donor liver transplants, with a family member donating part of their liver after full evaluation and approval by the authorisation committee under THOTA. The patient can also be registered with the state organ-sharing network under NOTTO. Where alcohol was involved, the team will also assess the patient's and family's commitment to lifelong abstinence — this is discussed in our article on alcohol and liver transplant.
Dr Bappaditya Har manages ACLF with the transplant hepatologists, intensivists and coordinators at Narayana RN Tagore Hospital, Mukundapur, Kolkata. Referring doctors and families can call 080675 06860, or send reports on WhatsApp to +91 70420 39420 for an early opinion.
If the patient recovers without a transplant
Some patients recover from an episode of ACLF, particularly when the trigger was treatable. They remain at high risk of another episode, so follow-up should include complete abstinence from alcohol, uninterrupted antiviral treatment where relevant, vaccination, cancer surveillance with six-monthly ultrasound, and a formal liver transplant evaluation so that plans are in place before any further crisis.
Frequently asked questions
What is the difference between ACLF and acute liver failure?
Acute liver failure happens in a person with no previous liver disease. ACLF happens in someone who already has chronic liver disease or cirrhosis and suddenly deteriorates, usually after a trigger such as alcohol, infection or a hepatitis flare.
Can a patient with ACLF recover?
Yes, some patients recover with intensive care, especially when the trigger is treated early and only one organ is affected. The chances fall as more organs fail, which is why early treatment in a liver unit matters.
Is liver transplant possible in ACLF?
In selected patients, yes. The transplant has to be done while the patient is still fit enough for surgery — usually within days to a few weeks of the illness. Uncontrolled infection or severe lung or circulatory failure can make transplant unsafe.
Can someone with alcohol-related ACLF get a transplant?
Many centres now consider carefully selected patients, even without a long period of abstinence, when there is strong family support and a clear commitment to never drinking again. Each case is assessed individually.
Why did my relative's hepatitis B flare?
The commonest reasons are stopping antiviral tablets without medical advice, or starting chemotherapy or strong steroids without protective antivirals. Hepatitis B medicines should never be stopped without a liver specialist's advice.
Related reading
Liver Failure Treatment →
Acute and chronic liver failure, and when transplant is needed.
Acute Liver Failure: Causes, Warning Signs and Emergency Transplant in Kolkata →
Acute liver failure is an emergency. Causes seen in India, warning signs, King's College criteria and why early transfer to a transplant centre matters.
Liver Cirrhosis Treatment in Kolkata: Stages, Care and When to Consider a Transplant →
Cirrhosis explained: compensated vs decompensated, Child-Pugh and MELD in plain words, what treatment can and cannot do, and when to consider a transplant.
Living Donor Liver Transplant →
A family member donates part of their liver; both recover.
Alcohol and Liver Transplant: The 6-Month Rule, Assessment and Life After →
Can someone with alcohol-related liver disease get a liver transplant? The 6-month abstinence rule, how teams assess patients today, and relapse risk.
This page is general patient information, not a diagnosis or a substitute for a consultation. Treatment decisions depend on each patient's reports and examination. Read our medical disclaimer and editorial policy.