Liver Failure may constitute one of the least favorite disease processes for anyone routinely taking care of critically ill patients. Intensivist and hepatology circles have begun to describe a specific population known as “Acute on Chronic Liver Failure” (ACLF).

These patients have chronic, progressive liver disease and then abruptly deteriorate due to any number of precipitating events (1,2). Unlike cases of acute hepatitis or paracetamol/acetaminophen overdose, the liver shut-down of ACLF is more a reaction to an inciting culprit, not the main event itself.

These episodes can happen at any time, even if outpatient management is going well.

Sometimes an ACLF flare is the first time someone’s chronic liver failure is recognized, especially in the medically underserved population.

The resulting clinical course is often catastrophic without prompt intervention.

As such, learning to identify these patients is essential.

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