Bench-to-beside review: Acute-on-chronic liver failure - linking the gut, liver and systemic circulation

The concept of acute-on-chronic liver failure (ACLF) was introduced recently to describe a subset of patients with chronic liver disease presenting with profound deterioration of liver function and rapidly evolving multi-organ failure. ACLF is frequently accompanied by the development of severe inflammatory response syndrome and has a high mortality. To date, treatment options are limited and exclusively supportive. Over the last few years, some insights have been generated in the pathophysiology of ACLF. A key role for the interaction of innate immune dysfunction, enhanced bacterial translocation from the gut, and circulatory dysfunction has been proposed. In this respect, therapeutic strategies have been examined, with variable success, in experimental studies in animals and humans. This review focuses on potentially relevant pathophysiological elements in the development of ACLF and points out promising treatment modalities in ACLF.


Pathophysiology of acute-on-chronic liver failure
Th ree main mechanisms are currently proposed as key elements in the development of ACLF: immune dys function, intestinal bacterial translocation, and circulatory dys function (Figure 1). We will discuss each of these elements separately and point out important interactions in the context of ACLF.

Innate immune dysfunction The innate immune system and Kupff er cells
Th e innate immune system serves as a fi rst-line defense mechanism against bacteria and toxins. It generates a non-pathogen-specifi c infl ammatory response after stimu lation with highly conserved antigens, such as lipopolysaccharides (LPSs). Th e main eff ector cells of the innate immune system are phagocytic cells, such as macrophages, neutrophils, and monocytes. Th e main cellular components of the innate immune system within the liver are the Kupff er cells. Th e liver is extremely important in innate immunity since Kupff er cells represent 80% to 90% of the tissue macrophages in the human body [12]. Th e strategic location of Kupff er cells within the lumen of the liver sinusoids and the anatomical location of the liver as a fi rst-line station for bacteria and toxins derived from the gut further stress the importance of the liver as a strategic immunological organ.

Classic mechanism of Kupff er cell activation
Several basic scientifi c data support the concept of innate immune dysfunction on the cellular and molecular level in ACLF. Th e main orchestrator of immune dysfunction in liver disease has proven to be the Kupff er cell An acute insult launches a liverdriven cascade of bacterial translocation from the gut, an inappropriate response from the innate immune system, and subsequent intra-and extrahepatic circulatory dysfunction, ultimately leading to multi-organ failure.
( Figure 2). Kupff er cells in healthy liver exert many roles: they inter vene in hemoglobin degradation, phagocytize bacteria and damaged cells, serve as antigen-presenting cells, and eliminate toxins such as ethanol [12,13]. Importantly, they interact intensively with other cells such as immune cells, sinusoidal endothelial cells, hepatocytes, and stellate cells, especially once they are activated. Kupff er cells are activated by many diff erent stimuli through Toll-like receptors (TLRs). Th is form of Kupff er cell activation is considered the classic pathway of Kupff er cell activa tion into so-called M1 proinfl am matory macrophages [14]. TLRs recognize multiple highly con served pathogen-associated molecular patterns (PAMPs) and damage-associated molecular pathways (DAMPs). Th e most common pathway of Kupff er cell activation is through activation by LPS or Gram-negative bacterial endo toxin [13,[15][16][17][18][19][20][21]. LPS binds to the acute-phase protein LPS-binding protein, enhancing interaction with the TLR4-CD14-MD2 receptor complex [22]. Th is interaction results in the recruitment of the adaptor molecules MyD88 and TRIF, which activate further downstream signaling cascades. Th e MyD88 signaling pathway is shared by all 13 members of the TLR family except for TLR3 [21]. Gram-positive bacteria interact with Kupff er cells through recognition of peptidoglycans and lipoproteins by the TLR2-TLR6 heterodimer complex [21,23]. Various other ligands such as viral RNA and necrotic cells have been identifi ed interacting with specifi c members of the TLR family. Th e role of complement receptors binding C3a and C5a has also been established in Kupff er cell activation [12]. Recently, a new mechanism of Kupff er cell activation by hydrogen peroxide was proposed [24].

Eff ects of classic Kupff er cell activation
Upon activation, Kupff er cells produce a great variety of infl ammatory mediators such as cytokines, chemokines, oxygen-derived free radicals, eicosanoids, and lysosomal and proteolytic enzymes [10,12,13,18]. Th e massive release of local proinfl ammatory cytokines such as interleukin (IL)-1, IL-6, IL-17, IL-18, and tumor necrosis factor-alpha (TNFα) and the release of anti-infl ammatory cytokines such as IL-4, IL-10, and IL-13 are considered causative in the subsequent development of SIRS and com pensatory anti-infl ammatory response syndrome (CARS) in acute and acute-on-chronic liver failure because of the overfl ow of these cytokines into the systemic circulation [25]. Among the proinfl ammatory cytokines, TNFα has been most intensively studied since it is fi rst released and correlates well with the overall severity of liver injury [26]. Cytokine release by Kupff er cells induces important leukocyte recruitment within the liver microvasculature and parenchyma. Th is is mediated in part by production of chemoattractants such as IL-8 and by expression of adhesion molecules such as ICAM-1 (intracellular adhesion molecule-1) and VCAM-1 (vascular cell adhesion molecule-1) on sinusoidal endothelial cells in response to liver injury [27]. Th is further leads to the production of oxidative stress and proteolytic enzymes, enhancing hepatocyte apoptosis and necrosis in liver disease. Kupff er cells are also responsible for the transformation of quiescent stellate cells into activated myofi broblasts, which drive the intrahepatic microcirculation. Furthermore, activated Kupff er cells produce vasoactive substances such as endothelin-1 (ET-1), thromboxane A 2 , nitric oxide (NO), and prostaglandins, thereby establishing a direct link between immune activation and hepatic microcirculatory dysfunction [28]. Further evidence for this link is provided by a recent study demonstrating increases in portal hypertension in response to intraperitoneal LPS injection in rats [29].

Alternative activation of Kupff er cells
On the other hand, Kupff er cells can be alternatively activated by cytokines such as IL-4 and IL-10, which are produced by Th 2 cells and other innate immune cells such as basophils. Upon alternative activation, they further diff erentiate into M2 phenotype macrophages [30]. Th ese M2-type macrophages exert mainly anti-infl am matory eff ects through mediators such as transforming growth factor-beta [31].

Mechanisms of innate immune dysfunction in acute-onchronic liver failure
Th e mechanisms of innate immune dysfunction in liver cirrhosis and alcoholism are numerous. First, Kupff er cells are bypassed through multiple intra-and extrahepatic shunts in cirrhosis. Second, decreased liver protein synthesis generates defects in complement production, resulting in reduced opsonization capacity in chronic liver disease. Additionally, defi ciency of albumin in patients with cirrhosis is common. Albumin is known to have impor tant detoxifying qualities such as scavenging free radicals and LPSs [10]. Th ird, in cirrhosis, there is evidence for a dysfunc tional and hyporesponsive state of the innate immune system, a phenomenon that is known as immune para lysis [10,32]. Th is was also recently revealed in patients with ACLF [33]. Th e phenomenon of immune paralysis has been illustrated in the 2007 study of Lin and colleagues [32]: patients with Child-Pugh class C cirrhosis were shown to suff er from downregulation of HLA-DR expression, directly hampering the mono nuclear cell antigen-presenting capacity. On the other hand, the 2006 study by Tazi and colleagues [34] revealed an increased TNFα production after stimulation of mono cytes by LPS in patients with advanced cirrhosis. Interestingly, two other previously mentioned studies obtained opposite results in their patient groups, so these fi ndings remain a matter of debate [32,33]. A similar debate regards the phagocytic capacity of neutrophils in liver disease. Some studies suggested increased radical and elastase production in response to bacterial challenge as well as increased phagocytosis in portal hypertensive rats [35][36][37]. Other studies demonstrated phagocytic capacity impairment in patients with alcoholic cirrhosis [38]. Globally, experimental results point toward an overall activated state of the innate immune system in chronic liver disease and an overproduction of harmful substances such as free radicals and liver parenchymal injury as a consequence. Th is has been nicely illustrated by the use of gadolinium chloride in animal trials, depleting the liver of Kupff er cells. Kupff er cell-depleted rats showed substantially less liver damage after partial liver resection, LPS challenge, and alcohol-and acetaminophen-induced liver injury [15,[39][40][41]. More over, TNFα levels have been shown to be signifi cantly elevated in patients with advanced cirrhosis, further revealing the activated state of the immune system [33]. On the other hand, the activated immune cells appear to be dysfunctional, paralyzed, and energy-depleted, making patients susceptible to infections, as demonstrated by clinical data. Th ese fi ndings seem to be exacerbated in the context of ACLF, resulting in an exaggerated SIRS and a defective CARS, a phenomenon known in the literature as immunological dissonance [25,33]. Th e additional adverse eff ects of alcohol on immune function, especially on TLRs and cytokines, have been extensively studied [18][19][20]22,[42][43][44]. However, this topic is beyond the scope of our review.

Role of natural killer cells and natural killer T cells
Recently, interest has arisen for other components of the innate immune system: the natural killer (NK) cells and the NK T cells. Although their role in ACLF has not yet been clearly elucidated, they obviously play an important role in many experimental models of liver injury, such as alcoholic liver disease, viral hepatitis, and autoimmune liver disease [45]. Furthermore, both NK and NK T cells are activated by bacterial toxins and bacterial superantigens and display hepatotoxicity through secretion of proinfl ammatory mediators such as TNFα. However, anti-infl ammatory markers, such as interferon-gamma, also are expressed by NK cells upon activation [46]. Future research will need to reveal the role of NK cells in the specifi c context of ACLF.

Innate immune dysfunction in acute-on-chronic liver failure on the clinical level
Th e presence of innate immune dysfunction in ACLF can be deducted from several observations in the context of ACLF, chronic liver disease, and alcoholism. Th e fi rst evidence comes from clinical observations: infection is the reason for hospital admission in 15% to 35% of patients with cirrhosis, and 15% to 35% of the patients develop nosocomial infections in comparison with 5% to 7% in the general population [10]. Also, roughly one third of patients with advanced cirrhosis and culture-negative ascites exhibit bacterial DNA in circulation, which is closely correlated to the presence of intrahepatic and systemic endothelial dysfunction [47,48]. Furthermore, a large majority of patients with ACLF display sepsis-like characteristics such as the SIRS (Table 1) [3].

Therapeutic strategies
Many strategies have been attempted, with variable success, to modify or attenuate the immune response in acute, chronic, or acute-on-chronic liver disease. Th e appli cation of corticosteroids in severe acute alcoholic hepatitis is well established [49]. Recently, more evidence has been generated regarding the benefi cial eff ects of pentoxifylline, an inhibitor of TNFα, in the treatment of not only severe alcoholic hepatitis but also advanced cirrhosis [50,51]. Th e benefi cial eff ect of TNFα monoclonal antibodies in severe alcoholic hepatitis is still controversial because, in one study, this was associated with higher infection and mortality rates [52]. Currently, a lot of scientifi c eff ort is put into targeting of innate immunity with TLR agonists and antagonists, but it is still unclear whether this is benefi cial in the treatment of patients with liver disease [53].

Intestinal bacterial translocation Defi nition and prevalence of intestinal bacterial translocation
Bacterial translocation is defi ned as the migration of viable microorganisms from the gut lumen to the mesenteric lymph nodes (MLNs) or extra-intestinal sites [54]. It seems to be of importance in cirrhosis and ACLF for two reasons. First, in patients with cirrhosis, bacterial translocation from the gut is a well-known source of lifethreatening infection, such as spontaneous bacterial peritonitis. Th is represents an acute event in chronic liver disease, which in some patients results in ACLF. Second, bacterial translocation is thought to induce and perpetuate the previously mentioned activated state of the innate immune system [55]. Bacterial translocation has proven to be increased in experimental animal models of cirrhosis or portal hypertension and in human disease [47,[56][57][58][59][60]. Bacterial translocation has been demon strated especially by removal and culture of MLNs. Recently, bacterial DNA measurement in blood samples has proven to be a reliable, non-invasive, and probably more sensitive surrogate marker for translocation of viable bacteria in cirrhosis [48,60]. Th e prevalence of bacterial translocation is closely related to the severity of liver disease. For instance, bacterial translocation to MLNs has been demonstrated uniquely in animal models of cirrhosis in the presence of ascites [58]. Furthermore, in a large study in humans, only the Child-Pugh class and not the degree of portal hyper tension was a predictive factor for the prevalence of bacterial translocation, suggesting that liver dysfunction might be more crucial in the development of bacterial translocation than portal hypertension in itself [57]. In that study, the prevalence of bacterial translocation increased according to the Child-Pugh classifi cation: 3.4% in Child A, 8.1% in Child B, and 30.8% in Child C cirrhotic patients. However, this concept was challenged in two earlier experimental studies, in which acute (2-day) portal hypertension induced bacterial transloca tion in partial portal vein-ligated rats without liver disease [56]. In another study, bacterial translocation could also be demonstrated in rats with chronic portal hyper tension, induced by means of partial portal vein ligation [59]. Moreover, it has been demonstrated that a second, acute injury to the system, such as hemorrhagic shock, further increases bacterial transloca tion from the gut, indicating its potentially important role in ACLF [59,61]. Th e presence of bacterial DNA in patients with cirrhosis proved, in a recent study, to be closely correlated to systemic and intrahepatic micro circulatory abnormalities [47]. Th is confi rms once more the close link between circulatory dysfunction, immune dysfunction, and bacterial translocation in liver disease. Heart rate of greater than 90 beats per minute Respiratory rate of greater than 20 breaths per minute or arterial partial pressure of carbon dioxide (PaCO 2 ) of less than 32 mm Hg White blood cell count of greater than 12,000 cells/mm 3 or less than 4,000 cells/mm 3 or greater than 10% immature forms

Mechanisms of bacterial translocation
Bacterial translocation originates from a large variety of dysfunctions within the gut-liver axis. Th ree key elements are recognized: changes in intestinal microfl ora, changes in intestinal permeability, and inadequate response of the gut immune system [55].

Changes in intestinal microfl ora
Th e microorganisms that are most frequently involved in bacterial translocation in humans are aerobic bacteria such as Escherichia coli, Klebsiella spp., Staphylococcus aureus, and Enterococcus [48]. In normal intestines, anaerobic bacteria, which rarely translocate, outnumber aerobic bacteria by 100:1 to 1,000:1 [62]. Anaerobic bacteria are known to prevent aerobic bacterial over growth. In patients with cirrhosis, bacterial over growth and changes in intestinal bacterial compo sition which were attributed largely to alterations in short-bowel motility and intestinal transit time have been docu mented [63,64]. Th is off ers, in part, an explanation why aerobic bacteria are capable of translocating from the intestine in patients with cirrhosis.

Increased intestinal permeability
Another explanation for bacterial translocation is that patients with cirrhosis display increased intestinal per meability. In normal circumstances, intestinal permea bility to water-soluble molecules is determined by the presence of tight junctions between intestinal epithelial cells [65]. Th ese tight junctions restrict diff usion of molecules up to 2 kDa through the paracellular space, preventing migration of bacteria but also of bacterial endotoxins through the intestinal epithelium [55]. In patients with cirrhosis, permeability was shown to be increased [66]. Th is is easy to conceive given the major morphological changes that occur in the intestinal epithelium in rat models of experimental cirrhosis. For instance, the viability of enterocytes in these rats was decreased, the villus fraction of enterocytes was heavily reduced, and (importantly) the cytoskeleton displays important morphological changes in cirrhosis [67]. Th e increases of intestinal permeability in cirrhosis have been attributed to the role of oxygen free radical damage, venous congestion, NO, and the direct eff ects of alcohol on the gut barrier [22,47,61,67].

Innate immune dysfunction in the gut
Finally, in normal circumstances, translocated microorgan isms are easily phagocytized and removed by intestinal macro phages. However, in chronic liver disease, this bac teri cidal capacity is reduced, as discussed in the above sections.

Therapeutic strategies
Strategies to prevent translocation of aerobic bacteria from the gut have been successfully applied in patients with cirrhosis. For instance, antibiotics such as norfl oxacin, known to selectively decontaminate the gut from Gram-negative bacteria, are used in variceal bleeding and the prevention of spontaneous bacterial peritonitis [68]. Furthermore, Tazi and colleagues [69] demonstrated that the hyperdynamic circulatory syndrome could be ameliorated by norfl oxacin. Of interest, in a recent study in 30 patients with decompensated cirrhosis, a signifi cant reduction of systemic and splanchnic plasma endotoxin levels but also a signifi cant reduction of hepatic venous pressure gradient (HVPG) values were seen after intestinal decontamination therapy with rifaximin [70]. Other strategies such as probiotics and intestinal prokinetics such as propranolol were successful in animal trials but need further validation in humans [71].

Circulatory dysfunction
Innate immune dysfunction and bacterial translocation in the onset of ACLF result in major alterations on the macrocirculatory and intrahepatic microcirculatory levels ( Figure 3).

Macrocirculatory level
On the macrocirculatory level, patients with ACLF display an aggravation of the hyperdynamic circulation, which is already present in advanced stages of com pensated cirrhosis. Cardiac output is increased and peripheral circulation is dilated and hyporesponsive. Mean arterial blood pressure is decreased. On the splanchnic level, there is important arterial vasodilatation and portal hypertension, resulting in renal hypoperfusion. Th is further leads to water and sodium retention by activation of the renin-angiotensin II-aldosterone pathway and secretion of antidiuretic hormone [2]. In patients with cirrhosis, two important mechanisms have been recognized in the development and aggravation of portal hyper tension. First, there is an increase of intrahepatic vascular resistance (IHVR), which can be attributed largely to alterations on the sinusoidal level [26]. Second, increased portal venous fl ow results from splanchnic hyperemia because of splanchnic arterial vasodilatation. Multiple factors have been implicated in these hemodynamic alterations.

Nitric oxide
An important role for NO is suggested on the peripheral as well as on the splanchnic level. NO is produced by two enzymes: one is an inducible isoform, iNOS, and the other is an endothelial constitutive isoform, eNOS. Th e latter proved to be the more important source of mesenteric artery NO overexpression in portal hypertension [72][73][74]. Th is up regu lation of eNOS is thought to originate from shear stress increases related to increased splanchnic infl ow [75]. Of interest in ACLF, an upregulation of eNOS was seen in rats with bacterial translocation, correlating to circulating TNFα levels and severity of intrahepatic microcirculatory dysfunction [76].

Microcirculatory level: stellate cells
On the hepatic level, IHVR has proven to be partly static and partly dynamic [77]. Th is can be attributed to the micro circulatory system within the liver sinusoids. Th e presence of vascular thrombi, collagen deposits within the space of Disse, and nodular regeneration explain the static component in IHVR. However, portal hypertension can be partially reversed by use of vasoactive substances in liver perfusion studies [78][79][80]. Th is represents a dynamic and modifi able part of portal hypertension. Th e contractile elements within the hepatic microcirculation have proven to be the stellate cells. Th is has been demonstrated in vitro, in stellate cell gel contraction models, and in in vivo microscopy studies. Th eir distri bution along the perisinusoidal space presents them with optimal sinusoidal constriction capacity. In normal liver, stellate cells are quiescent fat-storing cells. However, in the presence of liver injury, they become activated and proliferate into hepatic myofi broblasts. Th ese myofi broblasts develop contractile properties through cytoplasmic processes and acquisition of multiple smooth muscle proteins [81]. Hepatic stellate cell contraction is mediated through both Ca 2+ -dependent and independent pathways [82]. Also, the role of sinusoidal endothelial cells in micro vascular dysfunction in liver injury has been well established. Next to the production of vasoactive mediators such as NO and ET-1, sinusoidal endothelial cells are known to exert proinfl ammatory, proadhesive, and procoagulant properties upon activation [26]. Th rough close intercellular interaction with Kupff er cells and stellate cells, this vasomotor dysfunction is aggravated, probably promoting hepatocellular injury and a portal pressure increase in ACLF.

Endothelin-1
Many authors have concluded that the dynamic component of microcirculatory dysfunction within the liver must be due to overproduction or hyper-responsiveness to vasoconstrictors or to underproduction or hyporesponsive ness to vasodilators or to both. Many important vasoactive substances have since been identifi ed ( Table 2). Th e most important of these mediators are ET-1, NO, and carbon monoxide (CO). ET-1 is apparently the most important hepatic vasoconstrictor, directly interacting with the production of vasodilative substances such as NO and CO [26]. ET-1 is produced within liver sinusoidal endothelial cells, Kupff er cells, and stellate cells [28]. Increased plasma concentrations of ET-1 have been demonstrated in diff erent disease states, such as hemorrhagic shock, endotoxinemia, and polymicrobial sepsis [78,83]. Furthermore, chronic liver exposure to endotoxins enhances ET-1-mediated microcirculatory distur bances in experimental rat models [84]. Th is increased sensitivity is mediated through alterations in ET-1 receptor expression profi les on both sinusoidal endothelial cells and hepatic stellate cells [26]. ET-1 exerts its eff ect through ET A , ET B1 , and ET B2 receptors. ET A receptors, mediating vasoconstriction within the liver vasculature, have been shown to be downregulated in conditions of endotoxinemia and ischemia-reperfusion injury [83]. However, in experimental polymicrobial sepsis in rats, ET B2 receptor upregulation proves to be more important than ET A receptor downregulation, resulting in an overall exaggerated vasoconstrictive response to ET-1 [78,83]. Stellate cell-mediated vasoconstriction appears to be a crucial element in the development of ACLF. First, it contributes to sinusoidal perfusion failure, liver necrosis, and subsequent liver failure by impairing nutrient and oxygen supply to hepatocytes. Second, it aggravates portal hypertension and circulatory dysfunction and gives rise to typical vascular compli cations of acute-on-chronic liver disease, such as variceal bleeding. Th ese fi ndings on circulatory dysfunction off er, in part, an explanation for the development of ACLF in cirrhotic patients confronted with infection or gastrointestinal bleeding.

Adrenal insuffi ciency
Finally, in cirrhotic patients with renal failure or sepsis, a high incidence of adrenal insuffi ciency was found (range of 40% and 75%). Adrenal dysfunction seemed to be closely related to hemodynamic changes and mortality. Th e importance of this phenomenon and its potential therapeutic implications needs further validation [85].

Therapeutic strategies
ET-1 has been targeted in the experimental treatment of portal hypertension in multiple animal trials. Bosentan, for instance, a mixed ET A and ET B receptor antagonist, has proven to be benefi cial in the treatment of portal hypertension and portal hypertension-related complications such as variceal bleeding [86][87][88]. However, a recent European post-marketing study on the safety profi le of bosentan in the treatment of pulmonary hypertension in 4,994 patients demonstrated elevated aminotransferases in 7.6% of patients over a period of 3,416 patient-years [89]. However, this toxic eff ect proved to be early and mostly mild and transient. Of interest, in two studies, bosentan was safely administered to 93 Child A cirrhotic patients suff ering from portopulmonary hypertension [89,90]. Tezosentan, also a specifi c non-selective ET receptor antagonist, is also shown to limit liver injury in endotoxin-challenged cirrhotic rats [91]. In this respect, strategies to increase intrahepatic NO concentrations have been extensively studied. Replenishment of the defective eNOS enzyme has been obtained by NOS gene transfer in cirrhotic rats, attenuating portal hypertension [92]. Liver-directed NO donors have also been used with positive results in cirrhotic animal trials such as NOreleasing bile acids [93]. However, a recent randomized double-blind trial in humans failed to demonstrate portal pressure reduction in cirrhosis by means of NCX-1000, an NO-releasing derivative of ursodeoxycholic acid [94]. Also, statins are known to decrease the intrahepatic vascular tone in humans through an increase of hepatic NO production [95]. Th is is particularly important in ACLF since statins have been shown to improve outcome in sepsis, severe sepsis, and fatal sepsis [96,97]. Nitrofl urbiprofen, an NO-releasing cyclooxygenase inhibitor, was also proven to be benefi cial in rat models of cirrhotic portal hypertension [80]. Studies in patients on this topic are lacking. Furthermore, experimental studies examining the benefi cial eff ects in the specifi c context of ACLF need to be evaluated. Th e use of hydrocortisone in cirrhotic patients with documented adrenal insuffi ciency and septic shock is also under investigation. In a recent study by Arabi and colleagues [98] (2010), the administration of hydrocortisone in these patients resulted in higher shock reversal rates and less vasopressor use but signifi cantly more gastrointestinal bleeding and ultimately comparable survival rates in comparison with the placebo-treated group.

Conclusions
ACLF is an important clinical challenge since it remains a highly prevalent, life-threatening disease with few therapeutic options at present. Treatment options are currently limited to supportive measures. However, ACLF has proven to be a potentially reversible complication of chronic liver disease. Th is emphasizes the need for a guided therapeutic approach, shifting the downward spiral seen in ACLF toward hepatic recompensation. Th e application of liver support devices for this indication has been disappointing, although further analysis in certain subgroups of patients might be warranted [99,100]. In recent years, knowledge regarding the pathophysiology of ACLF has largely increased. All research has pointed toward the interaction between innate immune dysfunction, bacterial translocation from the gut, and (micro) circulatory dysfunction as key players. Th is has resulted in several treatment modalities proven to be benefi cial in animal or in vitro studies of liver disease. However, clinical studies in humans, especially in ACLF, are lacking.
A second strategy to prevent ACLF-related death might lie in the early recognition of this syndrome. For example, since the development of ACLF coincides with the development of multi-organ failure, early recognition of kidney injury by use of biomarkers of renal function could be useful in predicting the development of ACLF in cirrhotic patients confronted with acute disease [49]. It is likely that combining an early recognition of the syndrome with a more pathophysiology-guided therapeutic approach will result in better survival rates of patients with ACLF, also reducing the need for liver grafts as an ultimate salvage therapy.