This session will involve a review of the critical care management of multi-organ system dysfunction in acute on chronic liver failure (ACLF). Following a brief introduction of the pathophysiology related to splanchnic and systemic hemodynamic derangements, the session will systemically address management strategies related to organ system derangements, including hepatic encephalopathy, cardiovascular derangements, hepatopulmonary syndrome and portopulmonary hypertension, hepatorenal syndrome variceal bleeding, and abdominal compartment syndrome related to tense ascites. In addition, the role of liver transplant in the management of ACLF will be discussed.