Defining acute-on-chronic liver failure: East, West or Middle ground?

Table 1 Diagnostic criteria of acute-on-chronic liver failure as per the chronic liver failure acute-on-chronic liver failure in cirrhosis study

No ACLF - This group consists of 3 subgroups

Patients with no organ failure

Patients with a single "non-kidney" organ failure (i.e., single failure of the liver, coagulation, circulation, or respiration) who had a serum creatinine level < 1.5 mg/dL and no hepatic encephalopathy

Patients with single cerebral failure who had a serum creatinine level < 1.5 mg/dL

ACLF grade 1 - This group consists of 3 subgroups

Patients with single kidney failure

Patients with single failure of the liver, coagulation, circulation, or respiration who had a serum creatinine level ranging from 1.5 to 1.9 mg/dL and/or mild to moderate hepatic encephalopathy

Patients with single cerebral failure who had a serum creatinine level ranging from 1.5 and 1.9 mg/dL

ACLF grade 2 - This group consists of patients with 2 organ failures

ACLF grade 3 - This group consists of patients with 3 organ failures or more

Definitions of organ failures - CANONIC study

Liver failure - serum bilirubin level of 12.0 mg/dL or more

Kidney failure - serum creatinine level of 2.0 mg/dL or more, or the use of renal replacement therapy

Cerebral failure - grade III or IV hepatic encephalopathy

Coagulation failure - an international normalized ratio of more than 2.5 and/or a platelet count of 20 × 109/L or less

Circulatory failure - use of dopamine, dobutamine, or terlipressin

Respiratory failure - ratio of partial pressure of arterial oxygen to the fraction of inspired oxygen (FiO2) of 200 or less or a pulse oximetric saturation to FiO2 ratio of 200 or less

Adapted from Moreau et al[3]. ACLF: Acute-on-chronic liver failure; CANONIC: Chronic liver failure acute-on-chronic liver failure in cirrhosis.