Table 3 Principles of treatment for extrahepatic organ failures of ACLF

Coagulation

Perform the test of blood cell count and coagulation status;

Administer fibrinogen and/or platelets in patients with hypofibrinogenemia (< 1 g/L) and/or thrombocytopenia (< 20 × 10⁹/L) with invasive procedures;

Prophylaxis for deep-vein thrombosis in patients without severe coagulopathy

Avoid correction of INR with fresh frozen plasma for patients without bleeding or a planned procedure

Kidneys

Assess the severity of acute kidney injury (AKI) with modified KDIGO criteria of the International Club of Ascites;

20% albumin (1 g/kg for 48 h) for patients with AKI stage 2–3;

For patients with type-1 hepatorenal syndrome: 20% albumin (1 g/kg for 48 h and then 20–40 g/day) + terlipressin (2 mg/24 h) or norepinephrine (0.5 mg/hour, when terlipressin is not available);

RRT serves as a bridge to LT

Avoid nephrotoxic drugs, e.g., NSAIDs;

Avoid unnecessary RRT or early initiation of RRT

Respiration

Assess respiratory status (calculating the PaO2/FiO2 or SpO2/FiO2 and performing imaging examination);

Oxygen inhalation and lung protective ventilation strategy;

Endotracheal intubation for patients with West-Heaven grade 3–4 HE to facilitate airway management, prevent aspiration, and control ventilation;

PPIs are suggested to be used in patients on a ventilator

Avoid delay in intubation even if with normal blood oxygen level

Circulation

Assess haemodynamic state at admission;

Maintain mean arterial pressure  > 65 mmHg;

Norepinephrine is the first choice of vasopressor, epinephrine and terlipressin serve as additional agents;

Administer crystalloids and 5% albumin as resuscitation fluid;

Administer 20% albumin for patients with spontaneous bacterial peritonitis, large volume paracentesis or AKI

Avoid using starches formulations;

Limit saline solutions in patients with ascites or anasarca

Brain

Evaluation of the mental status, care of the airway, treatment of the precipitating factors, and empiric HE therapy should be performed simultaneously;

Use lactulose and enemas to clear the bowel;

Use short-acting sedative agents

Avoid deep sedation;

Avoid using benzodiazepines;

Ventilation in patients without altered mental status should not be considered as brain failure