A global consensus on the critical care management of acute-on-chronic liver failure patients: the APASL ACLF Beijing Position Paper

Chen T 1 , Choudhury A 2 , Liu W 1 , Zhang M 1 , Wu W 1 , Xiang H 1 Show all authors , Wang X 1 , Abbas Z 3 , Kanda T 4 , Idilman R 5 , Kalista KF 6 , Li H 7 , Mohamed RB 8 , Angeli P 9 , Elbasiony M 10 , Wijewantha HS 11 , Panackel C 12 , Thanapirom K 13 , Singal AK 14 , Win KM 15 , Shawcross DL 16 , Tapper EB 17 , Shrestha A 18 , Trebicka J 19 , Dokmeci AK 20 , Krag A 21 , Kulkarni AV 22 , Hu J 23 , Su H 23 , Adali G 24 , Kumar R 25 , Lau GK 26 , Arora A 27 , Fernandez J 28 , Tanwandee T 29 , Kim DJ 30 , Mamun-Al-Mahtab 31 , Hamid S 32 , Lesmana CRA 6 , Kabacam G 33 , Verma N 34 , Butt AS 35 , Huang DQ 36 , Taneja S 34 , Goel A 37 , Chirapongsathorn S 38 , Jafri W 35 , Maiwall R 2 , Dhiman RK 39 , Bajaj J 40 , Yaghi C 41 , Sharma BC 42 , Valsan A 43 , Fung J 44 , Premkumar M 34 , Karvellas CJ 45 , Kamani L 46 , Satapathy SK 47 , Bakulin IG 48 , Asrani S 49 , Ghazinian H 50 , Roy A 51 , Loho IM 52 , Payawal DA 53 , Shalimar 54 , Sharma MK 2 , Hernaez R 55 , Duan Z 56 , Rajaram RB 57 , Tanaka A 58 , Giri S 59 , Niriella MA 60 , Dadhich S 61 , Arora V 2 , Li J 62 , Azam MG 63 , Jalan R 64 , Kumar A 27 , Shukla A 65 , Kumar SE 37 , Wong VW 66 , Eapen CE 37 , Alam S 31 , Yu ML 67 , Chawla YK 59 , Shiha GE 10 , Duseja A 34 , Tan SS 68 , Choudhary NS 69 , Rela M 70 , Chan ACY 44 , Bhangui P 69 , Durand F 71 , Bataller R 72 , Muthiah MD 36 , Mahmud N 73 , Bhat M 74 , Saigal S 75 , Arab JP 76 , Kim YJ 77 , El-Sayed MH 78 , Hou J 79 , Jia J 80 , Ormeci N 81 , Wei L 82 , Omata M 83 , Kwo PY 84 , Sarin SK 85 , Ning Q 86 , APASL-ACLF Research Consortium (AARC) for APASL-ACLF Working Party

Affiliations 

  • 1 Department of Infectious Diseases, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Disease, Hubei Provincial Clinical Study Center of Viral Hepatitis, Huazhong University of Science and Technology, Wuhan Province, 430030, Hubei, China
  • 2 Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
  • 3 Ziauddin University Hospital, Karachi, Pakistan
  • 4 Division of Gastroenterology and Hepatology, Uonuma Institute of Community Medicine, Niigata University Medical and Dental Hospital, Minamiuonuma, 949-7302, Japan
  • 5 Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
  • 6 Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
  • 7 School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
  • 8 Department of Medicine, Faculty of Medicine, National University Malaysia, Kuala Lumpur, Malaysia
  • 9 Department of Medicine (DIMED), University of Padova, Padua, Italy
  • 10 Hepatology and Gastroenterology Unit, Department of Internal Medicine, Faculty of Medicine, Mansoura University, Mansoura, Egypt
  • 11 National Hospital-Kandy, Kandy, Sri Lanka
  • 12 Aster Medcity, Ernakulam, Kerala, India
  • 13 Division of Gastroenterology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
  • 14 Trager Transplant Center and Jewish Hospital, University of Louisville School of Medicine, Louisville, KY, USA
  • 15 University of Medicine, Yangon Ministry of Health, Yangon, Myanmar
  • 16 Roger Williams-Institute of Liver Studies, School of Immunology and Microbial Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
  • 17 Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, MI, USA
  • 18 Alka Hospital, Kathmandu, Nepal
  • 19 Medizinische Klinik B, Universitätsklinikum Münster, Münster, Germany
  • 20 Ankara University School of Medicine, Ankara, Turkey
  • 21 University of Southern Denmark, Odense, Denmark
  • 22 Department of Hepatology and Liver Transplantation, Asian Institute of Gastroenterology (AIG) Hospitals, Hyderabad, India
  • 23 The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, China
  • 24 University of Health Sciences, Ümraniye, Istanbul, Turkey
  • 25 Changi General Hospital, Singapore, Singapore
  • 26 Humanity and Health Medical Center, Hongkong, SAR, China
  • 27 Sir Ganga Ram Hospital, Rajender Nagar, New Delhi, India
  • 28 Liver ICU, Liver Unit, Hospital Clinic, IDIBAPS, University of Barcelona and CIBERehd, Barcelona, Spain
  • 29 Siriraj Hospital, Mahidol University, Bangkok, Thailand
  • 30 Hallym University, Chuncheon, Republic of Korea
  • 31 Bangladesh Medical University, Dhaka, Bangladesh
  • 32 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
  • 33 Department of Gastroenterology, Güven Hospital, Ankara, Turkey
  • 34 Department of Hepatology, PGIMER, Chandigarh, India
  • 35 Aga Khan University Hospital, Karachi, Pakistan
  • 36 Division of Gastroenterology and Hepatology, National University Hospital, Singapore, Singapore
  • 37 Christian Medical College (CMC), Vellore, India
  • 38 Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
  • 39 Sanjay Gandhi Post Graduate Institute (SGPGI), Lucknow, Uttar Pradesh, India
  • 40 Virginia Commonwealth University, Richmond, VA, USA
  • 41 Saint Joseph University, Hôtel-Dieu de France University Medical Center, Beirut, Lebanon
  • 42 Govind Ballabh Pant Hospital, New Delhi, India
  • 43 Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, India
  • 44 Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
  • 45 University of Alberta, Edmonton, AB, Canada
  • 46 Liaquat National Hospital, Karachi, Sindh, Pakistan
  • 47 Department of Gastroenterology and Transplant Hepatology, Donald and Barbara Zucker School of Medicine at Hofstra/Northwell, New Hyde Park, New York, 11040, USA
  • 48 A.S. Loginov Moscow Clinical Scientific Center of Moscow Healthcare Department, Moscow, Russia
  • 49 Baylor Simmons Transplant Institute, Dallas, TX, USA
  • 50 Yerevan Medical Scientific Center, Yerevan, Armenia
  • 51 Apollo Multispeciality Hospital, Kolkata, India
  • 52 Division of Gastroenterology and Hepatology, Dharmais National Cancer Hospital, Jakarta, Indonesia
  • 53 Fatima University Medical Center, Valenzuela Metro Manila, Philippines
  • 54 All India Institute of Medical Sciences (AIIMS), New Delhi, India
  • 55 Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine, Houston, TX, USA
  • 56 Liver Disease Center (Difficult and Complicated Liver Diseases and Artificial Liver Center), Beijing You'an Hospital Affiliated to Capital Medical University, Beijing, China
  • 57 University of Malaya, Kuala Lumpur, Malaysia
  • 58 Teikyo University School of Medicine, Tokyo, Japan
  • 59 Kalinga Institute of Medical Sciences (KIMS), Bhubaneshwar, Orissa, India
  • 60 University of Kelaniya, Ragama, Sri Lanka
  • 61 Dr. Sampurnanand Medical College and Associated Group of Hospitals (S N Medical College), Jodhpur, Rajasthan, India
  • 62 The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, People's Republic of China
  • 63 Endocrine and Metabolic Disorder (BIRDEM) Shahbad, Bangladesh Institute of Research and Rehabilitation in Diabetes, Dhaka, Bangladesh
  • 64 Liver Failure Group, UCL Institute for Liver and Digestive Health, London, UK
  • 65 Seth G S Medical College and K E M Hospital, Mumbai, Maharashtra, India
  • 66 Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China
  • 67 Hepatobiliary Division, Department of Internal Medicine, Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
  • 68 Selayang Hospital, Baru Caves, Selangor, Malaysia
  • 69 Medanta-The Medicity Hospital, Gurugram, Haryana, India
  • 70 Dr. Rela Institute and Medical Centre, Chennai, India
  • 71 Hepatology and Liver Intensive Care, Hospital Beaujon, University Paris Cité, Clichy, Paris, France
  • 72 Liver Unit, Hospital Clinic, Institut d'Investigacions Biomediques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
  • 73 University of Pennsylvania, Philadelphia, PA, USA
  • 74 Ajmera Transplant Program, University Health Network, Toronto, ON, Canada
  • 75 Max Super Specialty Hospital Saket, New Delhi, India
  • 76 Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
  • 77 Seoul National University College of Medicine, Seoul, Republic of Korea
  • 78 Ain Shams University, Cairo, Egypt
  • 79 Guangdong Provincial Key Laboratory of Viral Hepatitis Research, Guangdong Provincial Clinical Research Center for Viral Hepatitis, Key Laboratory of Infectious Diseases Research in South China, Ministry of Education, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, China
  • 80 Liver Research Center, Beijing Friendship Hospital, Capital Medical University, Beijing, China
  • 81 İstanbul Health and Technology University, Istanbul, Turkey
  • 82 Changgung Hospital, Tsinghua University, Beijing, China
  • 83 Yamanashi Central Hospital, Yamanashi, Japan
  • 84 Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA, USA. pkwo@stanford.edu
  • 85 Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India. shivsarin@gmail.com
  • 86 Department of Infectious Diseases, Tongji Hospital, Tongji Medical College and State Key Laboratory for Diagnosis and Treatment of Severe Zoonotic Infectious Disease, Hubei Provincial Clinical Study Center of Viral Hepatitis, Huazhong University of Science and Technology, Wuhan Province, 430030, Hubei, China. qning@vip.sina.com
Hepatol Int, 2026 Aug;20(4):963-991.
PMID: 42533257 DOI: 10.1007/s12072-026-11116-1

Abstract

BACKGROUND AND AIMS: Acute-on-chronic liver failure (ACLF) is a severe syndrome in patients with chronic liver disease, marked by rapid multi-organ failure and high short-term mortality. Managing ACLF requires intensive care, but standardized global guidelines were previously lacking. The APASL ACLF Research Consortium (AARC) developed this position paper to establish a unified, evidence-based consensus for its critical care management.

METHODS: A global collaboration of 109 experts employed a systematic methodology to address key aspects of ACLF care. Sections were drafted by specialist teams, with recommendations developed using the GRADE system. Draft statements underwent iterative review and refinement, followed by an expert panel consensus process consisting of open show-of-hands voting during the APASL Annual Conference in March 2025 in Beijing and a subsequent anonymous online voting round.

RESULTS: The consensus delivers 104 position statements. Key recommendations include using prognostic scores (AARC, CLIF-C ACLF, GIC) for ICU transfer and treatment decisions, and aggressively managing precipitating factors or complications like infections. It details organ-specific support for liver, kidney, and brain failure, advocating for early, targeted antibiotics and careful fluid management. The role of bridging therapies (plasma exchange, artificial liver systems) and nutritional support is emphasized. For transplantation, the guidelines provide criteria for patient selection and timing, particularly for alcohol-related ACLF.

CONCLUSIONS: The APASL ACLF Beijing Position Paper provides a comprehensive, standardized framework for managing critically sick ACLF patients. Integrating multidisciplinary expertise and current evidence, these guidelines aim to optimize care, inform clinical decisions, and improve survival for this high-risk population. As a few recommendations are supported predominantly by data from different continents, they should therefore be interpreted in local contexts.

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

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