Acute deterioration of patients with cirrhosis manifests as multiple organ failure requiring admission to an intensive care unit. Precipitating events may be viral hepatitis, typically in Asia, and drug or alcoholic hepatitis and variceal hemorrhage in the West. Patients with cirrhosis in the intensive care unit have a high mortality, and each admission is associated with a mean charge of US $116,200. Prognosis is determined by the number of organs failing (sequential organ failure assessment [SOFA] score), the presence of infection, and the degree of liver dysfunction (Child-Turcotte-Pugh or Model for End-Stage Liver Disease scores). The most common organ failing is the kidney; sepsis is associated with further deterioration in liver function by compromise of the microcirculation. Care of these critically ill patients with impending multiple organ failure requires a team approach with expertise in both hepatology and critical care. Treatment is aimed at preventing further deterioration in liver function, reversing precipitating factors, and supporting failing organs. Liver transplantation is required in selected patients to improve survival and quality of life. Treatment is futile in some patients, but it is difficult to identify these patients a priori. Artificial and bioartificial liver support systems have thus far not demonstrated significant survival benefit in these patients. (HEPATOLOGY 2011;54:1864-1872) Epidemiology: Patients with Cirrhosis Requiring Intensive Care A pproximately 26,000 patients with cirrhosis in the United States require intensive care each year, as identified by the need for mechanical ventilation and invasive cardiovascular monitoring. The in-hospital mortality in these patients is greater than 50%, and mean length of hospitalization is 13.8 days. The total annual charges associated with intensive care unit (ICU) admissions alone are US $3 billion, or mean charges of US $116,200 per admission (data not published). More concerning is the finding that ICU mortality rates associated with cirrhosis have remained essentially unchanged over 20 years. The optimal care of the patient with cirrhosis in the ICU is discussed in this review.