CASE 05•9–11 minutes•ACLF · Organ support · Prognostication · Goals of care

ACLF with worsening multiorgan failure: when does continued support stop helping?

A patient with ACLF continues to deteriorate despite full organ support. Work through sequential prognosis, transplant options and how to approach treatment limits without turning a score into a decision.

For clinicians working in critical care, hepatology and transplantation.

Use sequential rather than admission-only prognostication in ACLF.

Understand the role and limitations of CLIF-C ACLF and organ-failure burden in treatment-limit decisions.

Integrate transplant feasibility, reversibility, patient values and treatment burden into multidisciplinary decisions.

Day 1 · ICU

The admission

Stage 1 of 5

He has four organ failures. Is ICU already futile?

A 49-year-old man with decompensated alcohol-related cirrhosis is admitted with spontaneous bacterial peritonitis, septic shock, AKI and encephalopathy. Before this admission he was independent in activities of daily living and had been abstinent from alcohol for nine months.

He requires noradrenaline, invasive ventilation for grade III encephalopathy and respiratory failure, and continuous renal replacement therapy. Bilirubin is 310 µmol/L and INR 2.8.

Your decision

How should the initial treatment decision be framed?

Choose an approach to reveal the discussion and supporting evidence.

Educational content only. The case is fictional and does not replace local guidance, specialist advice or individual clinical judgement.

Clinical review: Dr Tom Dixon · 2026-09-28

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