EASL, AASLD, APASL, ALEH and SOLDA | Published 30 October 2026
Why this consensus matters
Acute-on-chronic liver failure (ACLF) can deteriorate over hours to days, yet existing regional definitions have not always identified the same patients. Five international liver societies have now proposed a harmonised framework for recognising and grading ACLF. The clinical aim is to identify patients with liver failure and evolving extrahepatic dysfunction early enough to treat reversible triggers, provide appropriate organ support and assess transplant suitability. The consensus also seeks more comparable research and trial populations; it does not establish that a new definition alone improves survival. Read the original consensus .
The core diagnostic framework
First establish advanced chronic liver disease (at least F3 fibrosis) or cirrhosis. The consensus defines the requisite liver failure as both INR ≥1.5 and bilirubin ≥5 mg/dL (approximately 85 µmol/L). Liver failure alone is not sufficient for its ACLF diagnosis: at least one qualifying extrahepatic organ dysfunction or failure must also be present. The thresholds are part of this new consensus framework and should not be silently substituted into a different regional ACLF score.
The syndrome can develop in someone with previously compensated advanced liver disease (type A) or with previously decompensated cirrhosis (type B). In type A, new ascites or hepatic encephalopathy may accompany liver failure at presentation or emerge within the following two to four weeks. Both hepatic and extrahepatic events can precipitate deterioration.
In an acutely ill patient, a high liver-stiffness measurement alone cannot prove pre-existing fibrosis: acute injury may increase stiffness. Use the history, prior records, laboratory findings, imaging, portal-hypertension evidence and, where appropriate, histology together to distinguish ACLF from acute liver failure. Source: definition and diagnostic statements .
How are the new grades assigned?
| Consensus grade | Required findings |
|---|---|
| Grade 1 | Liver failure plus one extrahepatic organ dysfunction. Circulatory or respiratory dysfunction counts here only in a monitored high-dependency or intensive-care setting. |
| Grade 2 | Liver failure plus one extrahepatic organ failure. |
| Grade 3 | Liver failure plus two or more extrahepatic organ failures. |
This grading includes dysfunction before established organ failure, an important distinction from older systems that primarily counted failures. Grade the patient repeatedly: an initial result is a starting point, not a fixed prognosis.
The consensus counts West Haven grade 3–4 hepatic encephalopathy as brain failure and KDIGO stage 2–3 acute kidney injury as renal failure. Respiratory failure includes the need for mechanical ventilation for a respiratory indication, a PaO₂/FiO₂ ratio ≤225, or a SpO₂/FiO₂ ratio ≤244 when an arterial oxygenation ratio is unavailable. Vasopressors for circulatory failure count as circulatory failure; vasopressor use solely to treat hepatorenal syndrome–AKI does not automatically do so. Respiratory and circulatory criteria require close monitoring and clinical interpretation. Source: organ-failure statements .
What should happen at the bedside?
Assess organ systems and look for a reversible precipitant in parallel. Review mental status, urine output and kidney injury, oxygenation and work of breathing, haemodynamics and signs of infection. Check for gastrointestinal bleeding, ongoing alcohol-related injury, viral hepatitis or reactivation, drug or herbal toxicity, and recent procedures when relevant. No trigger may be identifiable, but that should not stop a systematic search.
Bacterial infection is a frequent precipitant and complication. The consensus supports an early infection work-up, including diagnostic paracentesis when ascites is present, blood and urine cultures, and respiratory sampling when indicated. Start appropriate empirical antibiotics promptly when infection is suspected, guided by severity, likely source, local resistance and prior healthcare exposure; reassess and narrow therapy as results return.
Treat shock without reflexively giving unlimited fluid or albumin. Assess perfusion, volume status and cardiac function, using bedside echocardiography when available. Balanced crystalloids are preferred for initial resuscitation. Reserve albumin for established indications such as large-volume paracentesis, spontaneous bacterial peritonitis and hepatorenal syndrome–AKI, rather than routine use in every shocked patient with ACLF. If hypotension persists despite adequate intravascular volume, norepinephrine is the first-line vasopressor, with an initial mean arterial pressure target of at least 65 mmHg. Escalating vasopressor needs call for ICU-level reassessment; vasopressin is the proposed second-line agent.
For acute respiratory failure, a brief, closely monitored high-flow nasal oxygen trial may be appropriate in an alert patient who can protect the airway, but worsening gas exchange or work of breathing should not be allowed to delay intubation. When invasive ventilation is required, use lung-protective settings and individualise positive end-expiratory pressure to lung and haemodynamic physiology. The respiratory advice is partly extrapolated from general critical-care evidence rather than ACLF-specific trials. Source: critical-care statements .
Transplant assessment and serial decisions
Discuss severe ACLF with a liver-transplant team early, while treating potentially reversible precipitants and supporting failing organs. The window for transplantation can be narrow, and MELD alone may underestimate risk when extrahepatic failures predominate. Candidacy is a dynamic multidisciplinary judgement, not a decision made from one admission score or from the number of organ failures alone.
For patients with severe multiorgan failure who are not transplant candidates, the consensus supports an individualised, time-limited trial of intensive care when appropriate. Reassess the trajectory around days 3–7, alongside the patient’s wishes and goals of care. This is not a rule to withhold ICU admission at presentation: some precipitants are reversible. Palliative care can be integrated with active treatment and becomes central when recovery is no longer realistic. Source: ICU and transplantation statements .
What should clinicians keep in mind?
This is a multisociety consensus, not a randomised test of an ACLF treatment pathway. Statements were reviewed through a Delphi process and required more than 70% agreement; evidence strength varies across topics. The proposed grades offer a common language, but local protocols, critical-care resources and transplant access still affect decisions. Avoid treating a threshold or score as a substitute for repeated clinical assessment.
Practical takeaway: recognise underlying advanced liver disease, confirm the consensus liver-failure thresholds, identify extrahepatic dysfunction or failure, and actively treat triggers while arranging appropriate monitoring and early transplant discussion. Re-grade as the patient’s condition evolves.
Original publication
European Association for the Study of the Liver (EASL), American Association for the Study of Liver Diseases (AASLD), Asia-Pacific Association for the Study of the Liver (APASL), Latin American Association for the Study of the Liver (ALEH), and Society on Liver Disease in Africa (SOLDA). Acute-on-chronic liver failure: a global multisociety consensus on definitions. Hepatology International. Published online 30 October 2026. doi:10.1007/s12072-026-11169-2 .