Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations

Rahul Nanchal, Ram Subramanian, Waleed Alhazzani, Joanna C. Dionne, William J. Peppard, Kai Singbartl, Jonathon Truwit, Ali H. Al-Khafaji, Alley J. Killian, Mustafa Alquraini, Khalil Alshammari, Fayez Alshamsi, Emilie Belley-Cote, Rodrigo Cartin-Ceba, Steven M. Hollenberg, Dragos M. Galusca, David T. Huang, Robert C. Hyzy, Mats Junek, Prem KandiahGagan Kumar, Rebecca L. Morgan, Peter E. Morris, Jody C. Olson, Rita Sieracki, Randolph Steadman, Beth Taylor, Constantine J. Karvellas

Research output: Contribution to journalArticlepeer-review

3 Citations (Scopus)


OBJECTIVES: To develop evidence-based recommendations for clinicians caring for adults with acute liver failure (ALF) or acute on chronic liver failure (ACLF) in the ICU. DESIGN: The guideline panel comprised 27 members with expertise in aspects of care of the critically ill patient with liver failure or methodology. We adhered to the Society of Critical Care Medicine standard operating procedures manual and conflict-of-interest policy. Teleconferences and electronic-based discussion among the panel, as well as within subgroups, served as an integral part of the guideline development. INTERVENTIONS: In part 2 of this guideline, the panel was divided into four subgroups: neurology, peri-transplant, infectious diseases, and gastrointestinal groups. We developed and selected Population, Intervention, Comparison, and Outcomes (PICO) questions according to importance to patients and practicing clinicians. For each PICO question, we conducted a systematic review and meta-analysis where applicable. The quality of evidence was assessed using the Grading of Recommendations Assessment, Development, and Evaluation approach. We used the evidence to decision framework to facilitate recommendations formulation as strong or conditional. We followed strict criteria to formulate best practice statements. MEASUREMENTS AND MAIN RESULTS: We report 28 recommendations (from 31 PICO questions) on the management ALF and ACLF in the ICU. Overall, five were strong recommendations, 21 were conditional recommendations, two were best-practice statements, and we were unable to issue a recommendation for five questions due to insufficient evidence. CONCLUSIONS: Multidisciplinary, international experts formulated evidence-based recommendations for the management ALF and ACLF patients in the ICU, acknowledging that most recommendations were based on low quality and indirect evidence.

Original languageEnglish
Pages (from-to)657-676
Number of pages20
JournalCritical Care Medicine
Issue number5
Publication statusPublished - May 1 2023
Externally publishedYes


  • Development, and Evaluation
  • Grading of Recommendations Assessment
  • acute liver failure
  • acute on chronic liver failure
  • clinical practice guidelines

ASJC Scopus subject areas

  • Critical Care and Intensive Care Medicine


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