TNF and Sepsis: A down regulation of the expression of HLA-DR leads to decreased ex vivo production of cytokines following stimulation by lipopolysaccharide (LPS).[7] There are two studies that could demonstrate a reduced ex vivo tumour necrosis factor (TNF)-α secretion and HLA-DR expression on monocytes in patients with ACLF compared to patients with stable liver cirrhosis documenting a sepsis like immune paralysis in patients with ACLF.[7,8]