Akut-auf-chronisches Leberversagen

Das akut-auf-chronische Leberversagen (ACLF) ist ein lebensbedrohliches Syndrom bei Patienten mit dekompensierter Leberzirrhose, das durch das Versagen eines oder mehrerer Organsysteme charakterisiert ist. Trotz Fortschritten beim klinischen Management bleibt die Letalität des ACLF hoch. Dieser Artikel gibt basierend auf aktuellen Leitlinien einen praxisrelevanten Überblick zu Klassifikation, Diagnostik und Therapieoptionen des ACLF.

Abstract

Background

Acute-on-chronic liver failure (ACLF) is a life-threatening syndrome in patients with decompensated cirrhosis and is characterized by acute failure of one or more organ systems. Despite advances in clinical management, ACLF continues to be associated with high short-term mortality.

Methods

This article provides an up-to-date, guideline-based overview of the classification, diagnosis, and therapeutic approaches to ACLF, drawing on the latest literature and consensus definitions.

Results

ACLF is defined by acute decompensation of cirrhosis accompanied by failure of the liver and/or other organs including the kidneys, cardiovascular system, lungs, central nervous system, and coagulation. The EASL-CLIF Consortium criteria distinguish three grades of ACLF based on the number and type of organ failures; increasing grade correlates with sharply rising short- and medium-term mortality. Pathophysiologically, ACLF is characterized by an overwhelming systemic inflammatory response typically triggered by bacterial infections, severe alcoholic hepatitis, or gastrointestinal bleeding. Prognostication is guided by CLIF-C OF, CLIF-C ACLF, and CLIF-C AD scores, which can also help to identify patients at high risk for further decompensation. Management focuses on rapid identification and reversal of precipitating factors, organ support, and early evaluation for liver transplantation, as it remains the sole curative option in non-reversible ACLF. Preemptive TIPS placement is reserved for selected cases, with individualized risk assessment being critical due to the increased complication rate in severe multiorgan failure.

Conclusions

ACLF remains the most severe complication of cirrhosis, marked by high short-term mortality. Early, guideline-based interventions and multidisciplinary management can improve outcomes. Accurate risk stratification and timely consideration of liver transplantation are essential to enhance patient survival.

Kernaussagen

• Das ACLF ist die schwerste Form der akuten Dekompensation bei Leberzirrhose und geht mit einer sehr hohen Kurzzeitmortalität einher.

• Die Prognose hängt maßgeblich von der Zahl und Art der betroffenen Organsysteme ab; das Risiko steigt mit jedem zusätzlichen Organversagen deutlich.

• Pathophysiologisch steht eine überschießende systemische Inflammation im Vordergrund, die auf chronischer Leberschädigung beruht und durch akute Trigger verstärkt wird.

• Häufigste Auslöser sind bakterielle Infektionen, schwere alkoholische Hepatitis, gastrointestinale Blutungen und bestimmte Medikamente.

• Eine schnelle Identifikation und Behandlung dieser Auslöser sind entscheidend, um das Überleben zu verbessern.

• CLIF-C OF-, CLIF-C ACLF- und CLIF-C AD-Score sind zentrale Werkzeuge zur Risikoabschätzung, Therapieführung und Prognosebestimmung.

• Die Lebertransplantation ist derzeit die einzige kurative Option und sollte möglichst früh im Krankheitsverlauf geprüft werden.

• Ein präemptiver TIPS kann in ausgewählten Fällen mit schwerer Varizenblutung sinnvoll sein, ist jedoch bei schwerem Multiorganversagen kontraindiziert.

Schlüsselwörter

akut-auf-chronisches Leberversagen - Leberzirrhose - Organversagen - Infektion - Lebertransplantation

Keywords

acute-on-chronic liver failure - cirrhosis - organ failure - infection - liver transplantation

Publication History

Article published online:
09 February 2026

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