The Global ACLF Consensus : the 'Istanbul Document'

Kulkarni AV 1 , Choudhury A 2 , Arora V 2 , Dokmeci AK 3 , Koshy A 4 , Gurakar A 5 Show all authors , Duseja A 6 , Roy A 7 , Shukla A 8 , Krag A 9 , Kow AWC 10 , Shrestha A 11 , Kaewdech A 12 , Goel A 13 , Kumar A 14 , Singal AK 15 , Bwa AH 16 , Hongthanakorn C 17 , Lesmana CRA 18 , Huang D 10 , Crawford D 19 , Shawcross D 20 , Balchi D 21 , Agrawal D 22 , Payawal DA 23 , Song DS 24 , Kim DJ 25 , Bessone F 26 , Lau GK 27 , Germani G 28 , Pati GK 29 , Su GL 30 , Lee GH 10 , Adali G 31 , Szabo G 32 , Ghazinian H 33 , George J 34 , Fung J 35 , Bajaj J 36 , Javed P 37 , Jia J 38 , Lai JC 39 , Chen JJ 40 , Trebicka J 41 , Li J 42 , Patidar K 43 , Kalista KF 44 , Liu K 45 , Thanapirom K 46 , Wei L 47 , Azam MG 48 , Premkumar M 6 , Niriella M 49 , Alla M 1 , Pagadala M 50 , Kumar M 2 , Mendizabal M 51 , Pessoa MG 52 , Muthiah MD 10 , Omata M 53 , Noureddin M 54 , Karim MF 55 , Sharma M 1 , Alboraie M 56 , Elbasiony M 57 , Harputluoglu M 58 , Choudhary NS 59 , Selzner N 60 , Ormeci N 61 , Hernandez N 62 , Verma N 6 , Angeli P 63 , Charatcharoenwitthaya P 64 , Maji P 65 , Rathi P 66 , Dhiman RK 67 , Kumar R 68 , Maiwall R 2 , Idilman R 69 , Moreau R 70 , Gani RA 46 , Mohamed R 71 , Hamid SS 72 , Sachdeva S 73 , Kaur S 74 , Alam S 75 , Maung ST 76 , Tan SS 77 , Sowmya TR 1 , Sudhamshu KC 78 , Ramachandra S 1 , Dadhich SK 79 , Taneja S 6 , Giri S 80 , Singh S 67 , Chen T 81 , Gupta T 82 , Madke T 83 , Dayal VM 84 , Shantan V 1 , Pamecha V 2 , Jun WY 68 , Qi X 85 , Kim YJ 86 , Abbas Z 87 , Younossi ZM 88 , Sarin SK 89 , APASL-ACLF Research Consortium (AARC) for APASL-ACLF working party

Affiliations 

  • 1 Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology Hospitals, Hyderabad, India
  • 2 Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India
  • 3 Department of Medicine, Ankara University School of Medicine, Ankara, Turkey
  • 4 VPS Lakeshore Hospital and Research Center Ltd, Cochin, Kerala, India
  • 5 Johns Hopkins University Medical School, Baltimore, Maryland, USA
  • 6 Department of Hepatology, Post Graduate Institute of Medical Education and Research Chandigarh, Chandigarh, India
  • 7 Department of Gastroentrology , Institute of Gastrosciences and Liver Transplantation, Apollo Multispeciality Hospital, Kolkata, India
  • 8 Seth G S Medical College and K E M Hospital, Mumbai, Maharashtra, India
  • 9 Department of Clinical Research, University of Southern Denmark and Head of Hepatology,Odense University Hospital, University of Southern Denmark, Odense, Denmark
  • 10 Yong Loo Lin School of Medicine, National University of Singapore, Singapore, Singapore
  • 11 Department of Hepatology, Alka Hospital, Kathmandu, Nepal
  • 12 Prince of Songkla University, Hat Yai, Thailand
  • 13 Department of Hepatology , Christian Medical College, Vellore, India
  • 14 Sir Ganga Ram Hospital, Rajender Nagar, New Delhi, India
  • 15 University of Louisville, Louisville, USA
  • 16 Yangon GI & Liver Centre, Yangon, Myanmar
  • 17 Bhumibol Adulyadej Hospital, Bangkok, Thailand
  • 18 Dr. Cipto Mangunkusumo National General Hospital, Jakarta, Indonesia
  • 19 Gallipoli Medical Research Foundation, Green slopes Private Hospital, Green slopes, QLD, Australia
  • 20 Roger Williams Institute of Liver Studies School of Immunology and Microbial Sciences, Faculty of Life Sciences, King's College London, London, UK
  • 21 Bahçeşehir University (BAU) Chief of the Department of Surgery and Abdominal Transplantation, Istanbul, Turkey
  • 22 Continental Hospitals, Hyderabad, India
  • 23 Fatima University Medical Center Professor II and Chair of the Department of Internal Medicine, Valenzuela, Philippines
  • 24 The Catholic University of Korea, Seoul, Republic of Korea
  • 25 Hallym University College of Medicine, Chuncheon, South Korea
  • 26 Gastroenterology and Hepatology Department, Hospital Provincial del Centenario and Full Professor of Gastroenterology at the National University of Rosario School of Medicine in Rosario, Rosario, Argentina
  • 27 Humanity and Health Medical Center, SAR, Hongkong, China
  • 28 Department of Surgery Oncology and Gastroenterology - DISCOG Padua University Hospital, Padua, Italy
  • 29 IMS AND SUM Hospital, Siksha O Anusandhan, Bhubaneswar, India
  • 30 H. Marvin Pollard Collegiate Professor of Gastroenterology III and Professor of Medicine and Surgery at the University of Michigan Medical School, Ann Arbor, USA
  • 31 University of Health Sciences Istanbul Umraniye Training and Researc Hospital, Istanbul, Turkey
  • 32 Department of Medicine , Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, Massachusetts, USA
  • 33 Department Head of the Hepatology Nork Clinical Hospital of Infectious Diseases Yerevan, Yerevan, Armenia
  • 34 Storr Liver Centre Department of Gastroenterology Westmead Hospital and University of Sydney, Sydney, NSW, Australia
  • 35 Queen Mary Hospital, Hong Kong, China
  • 36 Hepatology and Nutrition, Virginia Commonwealth University and Richmond VA Medical Center, Richmond, USA
  • 37 Aster MIMS Hospital Kannur, Kannur, India
  • 38 Beijing Friendship Hospital, Capital Medical University, Beijing, China
  • 39 The Chinese University of Hong Kong, Hong Kong, China
  • 40 Director and Professor of Department of Hepatology and Infectious Diseases, Guangzhou, Guangdong Province, China
  • 41 Department of Internal Medicine B (Gastroenterology, Hepatology, Endocrinology, Infectious), Münster, Germany
  • 42 The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Republic of China
  • 43 Houston Methodist Hospital, Houston, USA
  • 44 Cipto Mangunkusumo Hospital, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
  • 45 Royal Prince Alfred Hospital, Sydney, Australia
  • 46 Division of Gastroenterology and Hepatology Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, Thailand
  • 47 Hepatopancreatobiliary Center, Beijing Tsinghua Changgung Hospital, Tsinghua University, Beijing, China
  • 48 Bangladesh Institute of Research & Rehabilitation in Diabetes , Endocrine and Metabolic Disorder (BIRDEM) Shahbad, Dhaka, Bangladesh
  • 49 Faculty of Medicine, University of Kelaniya, Ragama, Sri Lanka
  • 50 Liver Institute Methodist Dallas, Dallas, USA
  • 51 Hospital Universitario Austral, Buenos Aires, Argentina
  • 52 Division of Gastroenterology and Hepatology, University of São Paulo School of Medicine, São Paulo, SP, Brazil
  • 53 Department of Gastroenterology, Yamanashi Central Hospital, Yamanashi, Japan
  • 54 Department of Medicine, Professor at Houston Methodist Hospital, Houston, TX, USA
  • 55 Sir Salimullah Medical College Mitford Hospital, Dhaka, Bangladesh
  • 56 Department of Internal Medicine, Al-Azhar University, Cairo, Egypt
  • 57 Mansoura University, Mansoura, Egypt
  • 58 Inonu University Liver Transplant Institute Dept of Transplant Hepatology and Gastroenterology, Malatya, Türkiye
  • 59 Medanta The Medicity, Gurugram, India
  • 60 Ajmera Transplant Center University of Toronto, Toronto, Canada
  • 61 Department of Gastroenterology, İstanbul Health and Technology University, Istanbul, Türkiye
  • 62 The Unidad Academica de Gastroenterología. Hospital de Clinicas on Avenida Italia, Montevideo, Uruguay
  • 63 Unit of Internal Medicine and Hepatology, Department of Medicine (DIMED), University of Padova, Padua, Italy
  • 64 Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
  • 65 IMS & SUM Hospital-II, Bhubaneswar, Odisha, India
  • 66 T.N.Medical College, B.Y.L.Nair Ch Hospital, Mumbai, India
  • 67 Department of Hepatology, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, India
  • 68 Changi General Hospital, Singapore, Singapore
  • 69 Ankara University School of Medicine, Ankara, Turkey
  • 70 European Foundation for the Study of Chronic Liver Failure (EF CLIF), Avinguda Diagonal 477, Barcelona, Spain
  • 71 Department of Medicine, Faculty of Medicine, Universiti Kebangsaan Malaysia, Kuala Lumpur, Malaysia
  • 72 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
  • 73 GB Pant Hospital, New Delhi, India
  • 74 Queen Elizabeth Hospital, Sabah, Malaysia
  • 75 Bangladesh Medical University (BMU), Dhaka, Bangladesh
  • 76 Ma Har Myaing Hospital, Yangon, Myanmar
  • 77 Sunway Medical Center, Subang Jaya, Malaysia
  • 78 National Academy of Medical Sciences, Kathmandu, Nepal
  • 79 Dr Sampurnanand Medical College, Jodhpur, Rajasthan, India
  • 80 Kalinga Institute of Medical Sciences, Bhubaneswar, India
  • 81 Department of Infectious Diseases, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
  • 82 Division of Hepatology, Department of Medicine, Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India
  • 83 Ruby Hall Clinic, Pune, India
  • 84 IGIMS, Patna, India
  • 85 Liver Disease Center of Integrated Traditional Chinese and Western Medicine Department of Radiology, Medical School, Zhongdu Hospital, Southeast University, Nanjing, China
  • 86 Seoul National University College of Medicine, Seoul, Republic of Korea
  • 87 Dr. Ziauddin University Hospital Clifton, Karachi, Pakistan
  • 88 The Global Center for Liver Outcomes and Policy Research, Georgetown University School of Medicine, Washington DC, USA
  • 89 Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, India. sksarin@ilbs.in
Hepatol Int, 2026 Oct;20(5):1281-1294.
PMID: 42782569 DOI: 10.1007/s12072-026-11136-x

Abstract

The Kyoto Consensus introduced a key conceptual shift in characterizing acute-on-chronic liver failure (ACLF) patients into Type-A and Type-B phenotypes. A day-long meeting was convened at Istanbul during APASL 2026 to assess the real-world applicability of Type-A and Type-B ACLF across continents. The objective was that physicians could recognize ACLF as a unified disease entity, and quality research and new therapeutic options with defined end-points could be undertaken. Data from APASL ACLF Research Consortium (AARC), EASL-CLIF and NACSELD were assessed and discussed in detail. While the applicability of Type-A and Type-B varied across cohorts, the definition required to be appended. The experts unanimously agreed that 'liver failure' as identified by serum bilirubin of ≥ 5 mg/dl and INR ≥ 1.5 should be the 'core' for both Type-A and Type-B ACLF. Type-A ACLF is considered when "a patient with compensated advanced chronic liver disease or compensated cirrhosis presents with index decompensation as liver failure followed by development of ascites and/or hepatic encephalopathy within 4 weeks." Type-B ACLF is considered when "a patient with prior or concurrent decompensated cirrhosis presents with acute decompensation as liver failure accompanied by one or more extrahepatic organ failures." New definitions of organ dysfunction and failure, as well as endpoints for clinical trials, were also deliberated and finalized. The "Istanbul Report", presents a milestone evidence based consensus document carrying harmonization of various aspects of ACLF, incorporating current evidence, critically analyzed unanimous recommendations, and key areas for future studies.

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

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