Acute-on-chronic liver failure (ACLF): the 'Kyoto Consensus'-steps from Asia

Choudhury A 1 , Kulkarni AV 2 , Arora V 1 , Soin AS 3 , Dokmeci AK 4 , Chowdhury A 5 Show all authors , Koshy A 6 , Duseja A 7 , Kumar A 8 , Mishra AK 9 , Patwa AK 10 , Sood A 11 , Roy A 12 , Shukla A 13 , Chan A 14 , Krag A 15 , Mukund A 1 , Mandot A 16 , Goel A 9 , Butt AS 17 , Sahney A 18 , Shrestha A 19 , Cárdenas A 20 , Di Giorgio A 21 , Arora A 22 , Anand AC 23 , Dhawan A 24 , Jindal A 1 , Saraya A 1 , Srivastava A 9 , Kumar A 1 , Kaewdech A 25 , Pande A 26 , Rastogi A 1 , Valsan A 27 , Goel A 28 , Kumar A 22 , Singal AK 29 , Tanaka A 30 , Coilly A 31 , Singh A 32 , Meena BL 1 , Jagadisan B 24 , Sharma BC 8 , Lal BB 1 , Eapen CE 28 , Yaghi C 33 , Kedarisetty CK 34 , Kim CW 35 , Panackel C 36 , Yu C 37 , Kalal CR 38 , Bihari C 1 , Huang CH 39 , Vasishtha C 1 , Jansen C 40 , Strassburg C 40 , Lin CY 41 , Karvellas CJ 42 , Lesmana CRA 43 , Philips CA 44 , Shawcross D 24 , Kapoor D 34 , Agrawal D 45 , Payawal DA 46 , Praharaj DL 23 , Jothimani D 47 , Song DS 35 , Kim DJ 48 , Kim DS 49 , Zhongping D 37 , Karim F 50 , Durand F 51 , Shiha GE 52 , D'Amico G 53 , Lau GK 54 , Pati GK 32 , Narro GEC 55 , Lee GH 56 , Adali G 57 , Dhakal GP 58 , Szabo G 59 , Lin HC 60 , Li H 61 , Nair HK 62 , Devarbhavi H 63 , Tevethia H 1 , Ghazinian H 64 , Ilango H 65 , Yu HL 37 , Hasan I 43 , Fernandez J 66 , George J 67 , Behari J 68 , Fung J 14 , Bajaj J 69 , Benjamin J 1 , Lai JC 70 , Jia J 37 , Hu JH 71 , Chen JJ 72 , Hou JL 72 , Yang JM 35 , Chang J 40 , Trebicka J 73 , Kalf JC 40 , Sollano JD 74 , Varghese J 75 , Arab JP 76 , Li J 77 , Reddy KR 78 , Raja K 79 , Panda K 32 , Kajal K 7 , Kumar K 80 , Madan K 81 , Kalista KF 43 , Thanapirom K 82 , Win KM 83 , Suk KT 48 , Devadas K 84 , Lesmana LA 85 , Kamani L 86 , Premkumar M 7 , Niriella MA 87 , Al Mahtab M 88 , Yuen MF 14 , Sayed MH 89 , Alla M 2 , Wadhawan M 18 , Sharma MK 1 , Sahu M 32 , Prasad M 1 , Muthiah MD 56 , Schulz M 90 , Bajpai M 1 , Reddy MS 74 , Praktiknjo M 40 , Yu ML 91 , Prasad M 92 , Sharma M 2 , Elbasiony M 52 , Eslam M 67 , Azam MG 93 , Rela M 47 , Desai MS 94 , Vij M 47 , Mahmud N 78 , Choudhary NS 3 , Marannan NK 47 , Ormeci N 95 , Saraf N 3 , Verma N 7 , Nakayama N 96 , Kawada N 97 , Oidov Baatarkhuu 98 , Goyal O 11 , Yokosuka O 99 , Rao PN 2 , Angeli P 100 , Parikh P 101 , Kamath PS 102 , Thuluvath PJ 103 , Lingohr P 40 , Ranjan P 104 , Bhangui P 3 , Rathi P 105 , Sakhuja P 8 , Puri P 69 , Ning Q 106 , Dhiman RK 9 , Kumar R 107 , Vijayaraghavan R 1 , Khanna R 1 , Maiwall R 1 , Mohanka R 108 , Moreau R 109 , Gani RA 43 , Loomba R 110 , Mehtani R 111 , Rajaram RB 112 , Hamid SS 17 , Palnitkar S 113 , Lal S 7 , Biswas S 104 , Chirapongsathorn S 114 , Agarwal S 104 , Sachdeva S 8 , Saigal S 81 , Kumar SE 28 , Violeta S 115 , Singh SP 1 , Mochida S 96 , Mukewar S 116 , Alam S 1 , Lim SG 56 , Alam S 88 , Shalimar 104 , Venishetty S 2 , Sundaram SS 117 , Shetty S 118 , Bhatia S 119 , Singh SA 81 , Kottilil S 120 , Strasser S 121 , Shasthry SM 1 , Maung ST 82 , Tan SS 122 , Treeprasertsuk S 82 , Asthana S 123 , Manekeller S 40 , Gupta S 81 , Acharya SK 124 , K C S 125 , Maharshi S 126 , Asrani S 127 , Dadhich S 128 , Taneja S 7 , Giri S 23 , Singh S 9 , Chen T 106 , Gupta T 129 , Kanda T 130 , Tanwandee T 131 , Piratvishuth T 25 , Spengler U 40 , Prasad VGM 94 , Midha V 11 , Rakhmetova V 132 , Arroyo V 109 , Sood V 1 , Br VK 133 , Wong VW 134 , Pamecha V 1 , Singh V 135 , Dayal VM 136 , Saraswat VA 80 , Kim W 137 , Jafri W 17 , Gu W 90 , Jun WY 107 , Qi X 138 , Chawla YK 23 , Kim YJ 139 , Shi Y 77 , Abbas Z 140 , Kumar G 1 , Shiina S 141 , Wei L 142 , Omata M 143 , Sarin SK 144 , APASL-ACLF Research Consortium (AARC) for APASL-ACLF working party

Affiliations 

  • 1 Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
  • 2 Asian Institute of Gastroenterology Hospitals, Hyderabad, India
  • 3 Medanta-The Medicity Hospital, Gurugram, Haryana, India
  • 4 Ankara University School of Medicine, Ankara, Turkey
  • 5 Institute of Post-Graduate Medical Education and Research (IPGMER), Kolkata, West Bengal, India
  • 6 VPS Lakeshore Hospital and Research Center Ltd, Kochi, Kerala, India
  • 7 Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
  • 8 Govind Ballabh Pant Hospital, New Delhi, India
  • 9 Sanjay Gandhi Post Graduate Institute (SGPGI), Lucknow, Uttar Pradesh, India
  • 10 King George's Medical University, Lucknow, India
  • 11 Dayanand Medical College, Ludhiana, India
  • 12 Apollo Multispeciality Hospital, Kolkata, India
  • 13 Seth G S Medical College and K E M Hospital, Mumbai, Maharashtra, India
  • 14 Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
  • 15 University of Southern Denmark, Odense, Denmark
  • 16 Global Hospital, Mumbai, India
  • 17 Aga Khan University Hospital, Karachi, Pakistan
  • 18 BLK-Max Super Specialty Hospital, New Delhi, India
  • 19 Alka Hospital, Kathmandu, Nepal
  • 20 Univerity of Barcelona Institut d'Investigacions Biomèdiques August Pi-Sunyer, Barcelona, Spain
  • 21 Hospital Papa Giovanni XXIII, Bergamo, Italy
  • 22 Sir Ganga Ram Hospital, Rajender Nagar, New Delhi, India
  • 23 Kalinga Institute of Medical Sciences (KIMS), Bhubaneshwar, Orissa, India
  • 24 King's College Hospital, London, UK
  • 25 Prince-of Song-Kla University, Songkhla, Thailand
  • 26 Fortis Hospital, Greater Noida, Uttar Pradesh, India
  • 27 Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, India
  • 28 Christian Medical College (CMC), Vellore, India
  • 29 University of Louisville School of Medicine, Trager Transplant Center and Jewish Hospital, Louisville, KY, USA
  • 30 Teikyo University School of Medicine, Tokyo, Japan
  • 31 Centre Hepato-Biliaire, Paul Brousse Hospital, Paris-Saclay University, Villejuif, France
  • 32 IMS and SUM Hospital, SOA University, Bhubaneswar, Odisha, India
  • 33 Saint Joseph University, Hôtel-Dieu de France University Medical Center, Beirut, Lebanon
  • 34 Gleneagles Global Hospitals, Hyderabad, Telangana, India
  • 35 The Catholic University of Korea, Seoul, Korea
  • 36 Aster Medicity, Ernakulam, Kerala, India
  • 37 Capital Medical University, Beijing, China
  • 38 Nanavati Max Super Specialty Hospital, Mumbai, Maharashtra, India
  • 39 Linkou Chang-Gung Memorial Hospital, Taoyuan, Taiwan
  • 40 Department of Internal Medicine I, University of Bonn, Bonn, Germany
  • 41 Linkou Medical Centre, Chang Gung Memorial Hospital, Keelung, Taiwan
  • 42 University of Alberta, Edmonton, AB, Canada
  • 43 Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
  • 44 The Liver Institute, Rajagari Hospital, Aluva, Kerala, India
  • 45 PACE Hospital, Hyderabad, India
  • 46 Fatima Medical University Hospital, Valenzuela Metro Manila, Philippines
  • 47 Dr. Rela Institute and Medical Centre, Chennai, India
  • 48 Hallym University, Chuncheon, Republic of Korea
  • 49 Korea University College of Medicine, Seoul, Republic of Korea
  • 50 Sir Salimullah Medical College, Mitford Hospital, Dhaka, Bangladesh
  • 51 Université de Paris, AP-HP, C, DMU DIGEST, Centre de Référence Des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de Recherche Sur L'inflammation, Inserm, Paris, France
  • 52 Mansoura University, Mansoura, Egypt
  • 53 Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
  • 54 Humanity and Health Medical Center, Hongkong, SAR, China
  • 55 Hospital Médica Sur, Mexico City, Mexico
  • 56 National University Hospital, National University of Singapore, Singapore, Singapore
  • 57 University of Health Sciences, Ümraniye, Istanbul, Turkey
  • 58 Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
  • 59 Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA
  • 60 Taipei Veterans General Hospital, Taipei, Taiwan
  • 61 School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
  • 62 Ernakulam Medical Center (EMC), Kinder Multispeciality Hospital, Kochi, Kerala, India
  • 63 St. John's Medical College and Hospital, Bangalore, India
  • 64 Yerevan Medical Scientific Center, Yerevan, Armenia
  • 65 MIOT International Hospital, Chennai, India
  • 66 University of Barcelona, IDIBAPS and CIBEREHD, Barcelona, Spain
  • 67 Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney, NSW, Australia
  • 68 Pittsburgh Liver Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
  • 69 Virginia Commonwealth University, Richmond, VA, USA
  • 70 University of California, San Francisco, San Francisco, CA, USA
  • 71 The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, China
  • 72 Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China
  • 73 Medizinische Klinik B, Universitätsklinikum Münster, Münster, Germany
  • 74 Department of Medicine, Cardinal Santos Medical Center, Manila, Philippines
  • 75 Gleneagles Global Hospital, Chennai, Tamil Nadu, India
  • 76 Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
  • 77 The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
  • 78 University of Pennsylvania, Philadelphia, PA, USA
  • 79 King's College Hospital London, Dubai, United Arab Emirates
  • 80 Mahatma Gandhi Medical College, Jaipur, Rajasthan, India
  • 81 Max Super Specialty Hospital Saket, New Delhi, India
  • 82 Chulalongkorn University, Bangkok, Thailand
  • 83 University of Medicine, Yangon Ministry of Health, Yangon, Myanmar
  • 84 Government Medical College, Thiruvananthapuram, Kerala, India
  • 85 Medistra Hospital, Jakarta, Indonesia
  • 86 Liaquat National Hospital, Karachi, Sindh, Pakistan
  • 87 University of Kelaniya, Ragama, Sri Lanka
  • 88 Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
  • 89 Ain Shams University, Cairo, Egypt
  • 90 Goethe University Clinic Frankfurt, Frankfurt, Germany
  • 91 Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
  • 92 VGM Gastro Hospital, Coimbatore, India
  • 93 Endocrine and Metabolic Disorder (BIRDEM) Shahbad, Bangladesh Institute of Research and Rehabilitation in Diabetes, Dhaka, Bangladesh
  • 94 Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
  • 95 İstanbul Health and Technology University, Istanbul, Turkey
  • 96 Saitama Medical University, Iruma-Gun, Japan
  • 97 Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
  • 98 Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
  • 99 Graduate School of Medicine, Chiba University, Chuo-Ku, Chiba, Japan
  • 100 Department of Medicine (DIMED), University of Padova, Padua, Italy
  • 101 Zydus Hospital, Ahmedabad, Gujarat, India
  • 102 Mayo Clinic College of Medicine and Science, Rochester, MN, USA
  • 103 Mercy Medical Center, Baltimore, USA
  • 104 All India Institute of Medical Sciences (AIIMS), New Delhi, India
  • 105 Topi Wala National (TN) Medical College and BYL Nair Charitable Hospital, Mumbai, India
  • 106 Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
  • 107 Changi General Hospital, Singapore, Singapore
  • 108 Sir HN Reliance Foundation Hospital, Girgaon, Mumbai, Maharashtra, India
  • 109 European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain
  • 110 University of California, San Diego, La Jolla, CA, USA
  • 111 Amrita Institute of Medical Sciences and Research Centre, Faridabad, Haryana, India
  • 112 University of Malaya, Kuala Lumpur, Malaysia
  • 113 Deenanath Mangeshkar Hospital and Research Centre, Pune, India
  • 114 Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
  • 115 Violeta Medical Centre, Yerevan, Armenia
  • 116 Midas Multispeciality Hospital Pvt. Ltd, Nagpur, Maharashtra, India
  • 117 Digestive Health Institute, Children's Hospital, Aurora, CO, USA
  • 118 Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India
  • 119 National Institute of Medical Sciences, Jaipur, India
  • 120 University of Maryland School of Medicine, Baltimore, USA
  • 121 Royal Prince Alfred Hospital, Sydney, Australia
  • 122 Selayang Hospital, University of Malaysia, Batu Caves, Selangor, Malaysia
  • 123 Aster CMI Hospital, Bengaluru, Karnataka, India
  • 124 KIIT University, Fortis Escorts Hospital, Okhla, New Delhi, India
  • 125 Bir Hospital, National Academy of Medical Sciences, Kathmandu, Nepal
  • 126 Sawai Man Singh (SMS) Medical College and Hospital, Jaipur, Rajasthan, India
  • 127 Baylor Simmons Transplant Institute, Dallas, TX, USA
  • 128 Dr Sampuranand Medical College (SNMC), Jodhpur, Rajasthan, India
  • 129 Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
  • 130 Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
  • 131 Siriraj Hospital, Mahidol University, Bangkok, Thailand
  • 132 Astana Medical University, Astana, Kazakhstan
  • 133 Mazumdar Shaw Medical Centre, Bangalore, Karnataka, India
  • 134 Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
  • 135 Punjab Institute of Liver and Biliary Sciences, Mohali, Punjab, India
  • 136 Indira Gandhi Institute of Medical Sciences, (IGIMS), Bely Road Patna, Bihar, India
  • 137 Stanford University, Stanford, CA, USA
  • 138 Medical School, Zhongda Hospital, Southeast University, Nanjing, China
  • 139 Seoul National University College of Medicine, Seoul, Republic of Korea
  • 140 Ziauddin University Hospital Karachi, Karachi, Pakistan
  • 141 Juntendo University, Tokyo, Japan
  • 142 Changgung Hospital, Tsinghua University, Beijing, China
  • 143 Yamanashi Central Hospital, Yamanashi, Japan
  • 144 Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India. shivsarin@gmail.com
Hepatol Int, 2025 Feb 17.
PMID: 39961976 DOI: 10.1007/s12072-024-10773-4

Abstract

Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the "APASL ACLF Research Consortium (AARC)" was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia-Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the 'Golden Therapeutic Window', the 'transplant window', and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The 'Kyoto APASL Consensus' presented below carries the final recommendations along with the relevant background information and areas requiring future studies.

* Title and MeSH Headings from MEDLINE®/PubMed®, a database of the U.S. National Library of Medicine.

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