A 58-year-old woman with decompensated cirrhosis secondary to primary biliary cholangitis (PBC) (baseline Child-Turcotte-Pugh class B8, MELD-Na 12) was admitted to the ICU because of grade 4 hepatic/portosystemic encephalopathy triggered by acute variceal bleeding, for which pre-emptive TIPS placement was performed. At ICU admission, the patient fulfilled criteria for ACLF grade 2. On day 3 of hospitalisation, her condition progressed to ACLF grade 3A due to the development of kidney failure and coagulation failure. She is currently being treated with albumin and terlipressin. The patient has no major comorbidities and showed no evidence of sarcopenia or frailty prior to hospitalisation.