What is ACLF?
Acute-on-Chronic Liver Failure (ACLF) is one of the most severe and rapidly fatal syndromes in hepatology. It is defined by the APASL (Asian Pacific Association for the Study of the Liver) as an acute hepatic insult superimposed on a previously diagnosed or undiagnosed chronic liver disease, presenting with jaundice (serum bilirubin ≥5 mg/dL) and coagulopathy (INR ≥1.5), complicated within 4 weeks by clinical ascites and/or encephalopathy in a patient without previous decompensation.
Dr. Chetan Kalal is one of India’s foremost experts in ACLF, has co-authored research contributing to the APASL AARC (ACLF Research Consortium) consensus, and manages ACLF cases at Gleneagles Hospital Mumbai.
AARC Score and Grading
The AARC score (0–15 points) uses six parameters to grade ACLF severity and predict 28-day mortality:
- Serum bilirubin
- INR (coagulation)
- Serum lactate
- Creatinine
- Hepatic encephalopathy grade
- Presence of infection
Grade 1 ACLF (AARC score 5–7): 28-day mortality approximately 15–20% with optimal medical therapy.
Grade 2 ACLF (AARC score 8–10): Intermediate mortality; intensive care mandatory.
Grade 3 ACLF (AARC score 11–15): 28-day mortality exceeds 70% without liver transplantation.
Common Precipitants of ACLF in India
- Hepatitis B reactivation (most common in Asia)
- Alcohol-related liver disease acute decompensation
- Bacterial infections — spontaneous bacterial peritonitis (SBP), pneumonia
- Superimposed drug-induced or herbal-induced liver injury (DILI/HILI)
- Superimposed hepatitis A or E on chronic liver disease
Treatment of ACLF
Grade 1: Intensive medical management — treat the precipitant, nutritional support (high-protein diet, BCAA supplementation if encephalopathy), lactulose, rifaximin for encephalopathy, prophylactic antibiotics for infection, and careful fluid management.
Grade 2–3: Refer immediately to a tertiary liver centre with ICU and liver transplant capabilities. Evaluate urgently for liver transplantation. The window for transplant is narrow — decisions must be made within 7–10 days of presentation.
Liver transplantation is the only definitive treatment for Grade 2–3 ACLF that does not respond to medical therapy. Living donor liver transplant (LDLT) is the preferred route in India given the limited deceased-donor pool.
Frequently Asked Questions about ACLF
Can ACLF patients survive without a liver transplant?
Grade 1 ACLF patients have a meaningful chance of survival with aggressive medical management, particularly if the precipitant is identified and treated early. Grade 2–3 ACLF carries high mortality without transplantation. Early AARC scoring on admission is essential to determine the trajectory and escalate care promptly.
How quickly does ACLF progress?
ACLF is a rapidly evolving condition. The AARC score should be reassessed at 72 hours and day 7 — an increasing score despite treatment is an indicator to expedite transplant referral. Some patients deteriorate from Grade 1 to Grade 3 within days.
Which hospital in Mumbai treats ACLF?
Dr. Chetan Kalal at Gleneagles Hospital Mumbai specialises in ACLF management including intensive medical care and liver transplant evaluation for Grade 2–3 ACLF. Referrals from physicians across India and internationally are accepted.
Author: Dr. Chetan Kalal — First DM Hepatologist of Maharashtra, AASLD Foundation Award 2016 and 2017. ORCID: 0000-0002-5284-7890. Read more about ACLF treatment at Gleneagles Hospital Mumbai.
About the Author
Dr. Chetan Kalal — MBBS, MD (Internal Medicine), DM Hepatology (ILBS, New Delhi) — is the First DM Hepatologist of Maharashtra and Associate Director, Hepatology & Liver Transplant, at Gleneagles Hospital Mumbai. He has 26 peer-reviewed publications and serves on the APASL AARC Expert Panel. Fellow, National Academy of Medical Sciences (FNAMS). Learn more · Book appointment
