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While a clear definition of ACLF has been forwarded from a large European Consortium study, some heterogeneity remains in how patients present and the types of organ failure, depending on whether they are described in Asian or European studies. Active alcoholism, acute alcoholic hepatitis and infections are the most frequent precipitants for ACLF. Underpinning the pathophysiology of ACLF is a state of persistent inflammation and immune dysfunction, collectively driving a systematic inflammatory response syndrome and an increased propensity to sepsis. Prevention and early treatment of organ failure are key in influencing survival. Given increasing organ shortage and more marginal grafts, liver transplantation is a limited resource and emphasises the need for new therapies to improve ACLF outcomes. Recent data indicate that liver transplantation has encouraging outcomes even in patients with advanced ACLF if patients are carefully selected during the permissive window of clinical presentation. ACLF remains a significant challenge in the field of hepatology, with considerable research and resource being channelled to improve upon the definition, prognostication, treatment and unravelling of mechanistic drivers. This Review discusses updates in ACLF definition, prognosis and management.<\/jats:p>","DOI":"10.1136\/flgastro-2018-101103","type":"journal-article","created":{"date-parts":[[2019,11,25]],"date-time":"2019-11-25T17:15:34Z","timestamp":1574702134000},"page":"458-467","update-policy":"https:\/\/doi.org\/10.1136\/crossmarkpolicy","source":"Crossref","is-referenced-by-count":27,"title":["Acute-on-chronic liver failure: definition, prognosis and management"],"prefix":"10.1136","volume":"11","author":[{"given":"Ahmed","family":"Amin","sequence":"first","affiliation":[{"name":"Institute for Liver and Digestive Health, University College London, London, UK"},{"name":"Assiut University Faculty of Medicine, Assiut, Egypt"}],"role":[{"vocabulary":"crossref","role":"author"}]},{"ORCID":"https:\/\/orcid.org\/0000-0002-6275-9384","authenticated-orcid":false,"given":"Rajeshwar P","family":"Mookerjee","sequence":"additional","affiliation":[{"name":"Institute for Liver and Digestive Health, University College London, London, UK"}],"role":[{"vocabulary":"crossref","role":"author"}]}],"member":"239","published-online":{"date-parts":[[2019,11,25]]},"reference":[{"key":"2025090708375081000_11.6.458.1","doi-asserted-by":"publisher","DOI":"10.1111\/j.1478-3231.2012.02830.x"},{"key":"2025090708375081000_11.6.458.2","doi-asserted-by":"publisher","DOI":"10.1159\/000047017"},{"key":"2025090708375081000_11.6.458.3","doi-asserted-by":"publisher","DOI":"10.1053\/j.gastro.2013.02.042"},{"key":"2025090708375081000_11.6.458.4","doi-asserted-by":"crossref","first-page":"4","DOI":"10.1053\/j.gastro.2014.05.005","article-title":"Toward an improved definition of acute-on-chronic liver failure","volume":"147","author":"Jalan","year":"2014","journal-title":"Gastroenterology"},{"key":"2025090708375081000_11.6.458.5","doi-asserted-by":"crossref","first-page":"250","DOI":"10.1002\/hep.27077","article-title":"Survival in infection-related acute-on-chronic liver failure is defined by extrahepatic organ failures","volume":"60","author":"Bajaj","year":"2014","journal-title":"Hepatology"},{"key":"2025090708375081000_11.6.458.6","doi-asserted-by":"publisher","DOI":"10.1007\/s12072-008-9106-x"},{"key":"2025090708375081000_11.6.458.7","doi-asserted-by":"crossref","first-page":"1621","DOI":"10.1002\/hep.30056","article-title":"Acute-On-Chronic liver failure: getting ready for prime time?","volume":"68","author":"Bajaj","year":"2018","journal-title":"Hepatology"},{"key":"2025090708375081000_11.6.458.8","doi-asserted-by":"crossref","first-page":"856","DOI":"10.1111\/jgh.13213","article-title":"Acute on chronic liver failure because of acute hepatic insults: etiologies, course, extrahepatic organ failure and predictors of mortality","volume":"31","author":"Shalimar","year":"2016","journal-title":"J Gastroenterol Hepatol"},{"key":"2025090708375081000_11.6.458.9","doi-asserted-by":"crossref","DOI":"10.1038\/srep25487","article-title":"Characteristics, diagnosis and prognosis of acute-on-chronic liver failure in cirrhosis associated to hepatitis B","volume":"6","author":"Li","year":"2016","journal-title":"Sci Rep"},{"key":"2025090708375081000_11.6.458.10","doi-asserted-by":"crossref","unstructured":"Arroyo V , Moreau R , Kamath PS , et al . 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