GI Endoscopy · 7 min read
ACLF: Organ Failures on the CLIF Score, Not Just Another Decompensation
Ascites alone is not ACLF. Kidney, brain, circulation, lung, liver, or coagulation failure on the CLIF-C OF scale is.
ACLF is acutely decompensated cirrhosis plus organ-system failure and a short mortality that ordinary decompensation does not have. EASL 2023 (PMID 37364789) uses the six-organ CLIF-C OF score. Infection and alcohol-related hepatitis are the usual precipitants. Treat those, support the organs, and score again. Transplant is a therapy, not a late thought.
Experienced teaching points
Clinical Pearls
- ACLF is not 'sick cirrhosis.' It is organ failure on a CLIF definition plus a 28-day death risk that should change the room the patient goes to.
- Single kidney failure can be ACLF-1. Isolated mild encephalopathy with a creatinine under 1.5 mg/dL is not.
- Score CLIF-C ACLF more than once. Trajectory is the futility and transplant conversation.
- Find the precipitant: infection (including SBP), alcohol-related hepatitis, GI bleed, drug injury. There is not always a named one.
- Bleed bundle: vasoactive drugs and albumin and TIPS. Banding technique is the variceal page.
Clinical Bottom Line
| Piece | EASL 2023 practical answer |
|---|---|
| Definition | Acutely decompensated cirrhosis plus failure of one or more of six systems on CLIF-C OF (liver, kidney, brain, coagulation, circulation, lung) and a high 28-day mortality (PMID 37364789). |
| Grade | ACLF-1: typically single kidney failure, or one other failure plus kidney dysfunction or mild HE. ACLF-2: two failures. ACLF-3: three or more. Grade tracks 28-day death. |
| Score | CLIF-C ACLF uses OF score, age, and white count. Repeat it. A calculator lives at efclif.com. |
| First moves | Cultures, source control, albumin when the indication is SBP or HRS, stop hepatotoxins, ICU if the organs need support. Steroids for alcohol-related hepatitis only after you have excluded infection and you will use a Lille stop rule. |
| Transplant | Selected ACLF, including ACLF-3, can still be transplanted with acceptable outcomes if the window is short. Sequential scoring is how you stop futile ICU without missing that window. |
Why isn't this just decompensation?
Ordinary acute decompensation is ascites, bleed, or encephalopathy without extra-hepatic organ failure. ACLF adds kidney, brain, circulation, lung, liver, or coagulation failure and a 28-day mortality that often sits above 20-30% and climbs with grade. The leftover stub on this URL listed SBP, alcohol, and variceal bleed as if they were ACLF itself. They are precipitants. The diagnosis is the organ-failure pattern.
EASL uses CLIF, not NACSELD, as the operational European definition. NACSELD is stricter (two extra-hepatic failures) and will miss ACLF-1. Do not mix the scores in the same sentence as if they were interchangeable.
What to do in the first day
Assume infection until cultures say otherwise. Diagnostic tap if there is ascites. Broad antibiotics when sepsis or SBP is plausible. Organ support in ICU when circulation, lungs, or grade 3-4 HE need it. Do not use the leftover stub's 'STAT albumin for every cytokine storm.' Albumin has indications: SBP (Sort 1999, PMID 10438259), large-volume paracentesis, and HRS-AKI with a vasoconstrictor. That argument lives on the albumin page.
Variceal bleed still gets the Baveno bundle and a TIPS question: TIPS page. Do not restage banding here.
Selected references
- EASL Clinical Practice Guidelines on acute-on-chronic liver failure. J Hepatol. 2023;79:461-491.
- Sort P, et al. Effect of intravenous albumin on renal impairment and mortality in cirrhosis with spontaneous bacterial peritonitis. N Engl J Med. 1999;341:403-409.
Last reviewed September 20, 2026. Written for clinicians looking at a newly jaundiced, infected, or bleeding cirrhotic and deciding whether this is ACLF and whether ICU plus transplant evaluation is the next hour.
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