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Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update

Sarin SK 1 , Choudhury A 2 , Sharma MK 2 , Maiwall R 2 , Al Mahtab M 3 , Rahman S 3 Show all authors , Saigal S 4 , Saraf N 4 , Soin AS 4 , Devarbhavi H 5 , Kim DJ 6 , Dhiman RK 7 , Duseja A 7 , Taneja S 7 , Eapen CE 8 , Goel A 8 , Ning Q 9 , Chen T 10 , Ma K 9 , Duan Z 10 , Yu C 10 , Treeprasertsuk S 11 , Hamid SS 12 , Butt AS 12 , Jafri W 12 , Shukla A 13 , Saraswat V 14 , Tan SS 15 , Sood A 16 , Midha V 16 , Goyal O 16 , Ghazinyan H 17 , Arora A 18 , Hu J 19 , Sahu M 20 , Rao PN 21 , Lee GH 22 , Lim SG 22 , Lesmana LA 23 , Lesmana CR 23 , Shah S 24 , Prasad VGM 25 , Payawal DA 26 , Abbas Z 27 , Dokmeci AK 28 , Sollano JD 29 , Carpio G 29 , Shresta A 30 , Lau GK 31 , Fazal Karim M 32 , Shiha G 33 , Gani R 34 , Kalista KF 34 , Yuen MF 35 , Alam S 36 , Khanna R 36 , Sood V 36 , Lal BB 36 , Pamecha V 37 , Jindal A 2 , Rajan V 2 , Arora V 2 , Yokosuka O 38 , Niriella MA 39 , Li H 40 , Qi X 41 , Tanaka A 42 , Mochida S 43 , Chaudhuri DR 44 , Gane E 44 , Win KM 45 , Chen WT 46 , Rela M 47 , Kapoor D 24 , Rastogi A 4 , Kale P 48 , Rastogi A 49 , Sharma CB 49 , Bajpai M 50 , Singh V 7 , Premkumar M 7 , Maharashi S 51 , Olithselvan A 52 , Philips CA 53 , Srivastava A 54 , Yachha SK 54 , Wani ZA 55 , Thapa BR 56 , Saraya A 57 , Shalimar 57 , Kumar A 18 , Wadhawan M 58 , Gupta S 59 , Madan K 60 , Sakhuja P 61 , Vij V 62 , Sharma BC 63 , Garg H 64 , Garg V 64 , Kalal C 65 , Anand L 66 , Vyas T 67 , Mathur RP 68 , Kumar G 69 , Jain P 69 , Pasupuleti SSR 69 , Chawla YK 70 , Chowdhury A 71 , Alam S 3 , Song DS 72 , Yang JM 72 , Yoon EL 73 , 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. sksarin@ilbs.in
  • 2 Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
  • 3 Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
  • 4 Department of Hepatology, Medanta The Medicity, Gurgaon, India
  • 5 Department of Hepatology, St John Medical College, Bangalore, India
  • 6 Department of Internal Medicine, Hallym University College of Medicine, Seoul, South Korea
  • 7 Department of Hepatology, PGIMER, Chandigarh, India
  • 8 Department of Hepatology, CMC, Vellore, India
  • 9 Institute and Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
  • 10 Translational Hepatology Institute Capital Medical University, Beijing You'an Hospital, Beijing, China
  • 11 Department of Medicine, Chulalongkorn University, Bangkok, Thailand
  • 12 Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
  • 13 Department of Gastroenterology, Lokmanya Tilak Municipal General Hospital and Lokmanya Tilak Municipal Medical College, Sion, Mumbai, India
  • 14 Department of Gastroenterology, SGPGIMS, Lucknow, India
  • 15 Department of Medicine, Hospital Selayang, Bata Caves, Selangor, Malaysia
  • 16 Department of Gastroenterology, DMC, Ludhiana, India
  • 17 Department of Hepatology, Nork Clinical Hospital of Infectious Disease, Yerevan, Armenia
  • 18 Department of Gastroenterology and Hepatology, Sir Ganga Ram Hospital and GRIPMER, New Delhi, Delhi, India
  • 19 Department of Medicine, 302 Millitary Hospital, Beijing, China
  • 20 Department of Gastroenterology and Hepatology Sciences, IMS & SUM Hospital, Bhubaneswar, Odisha, India
  • 21 Asian Institute of Gastroenterology, Hyderabad, India
  • 22 Division of Gastroenterology and Hepatology, Department of Medicine, National University Health System, Singapore, Singapore
  • 23 Digestive Disease and GI Oncology Centre, Medistra Hospital, Jakarta, Indonesia
  • 24 Department of Hepatology, Global Hospitals, Mumbai, India
  • 25 Department of Gastroenterology, VGM Hospital, Coimbatore, India
  • 26 Fatima University Medical Center Manila, Manila, Philippines
  • 27 Department of Medicine, Ziauddin University Hospital, Karachi, Pakistan
  • 28 Department of Medicine, Ankara University School of Medicine, Ankara, Turkey
  • 29 Department of Medicine, University of Santo Tomas, Manila, Philippines
  • 30 Department of Hepatology, Foundation Nepal Sitapaila Height, Kathmandu, Nepal
  • 31 Department of Medicine, Humanity and Health Medical Group, New Kowloon, Hong Kong, China
  • 32 Department of Hepatology, Sir Salimullah Medical College, Dhaka, Bangladesh
  • 33 Egyptian Liver Research Institute And Hospital, Cairo, Egypt
  • 34 Division of Hepatobiliary, Department of Internal Medicine, Faculty of Medicine, Cipto Mangunkusumo Hospital, Universitas Indonesia, Jakarta, Indonesia
  • 35 Department of Medicine, Queen Mary Hospital Hong Kong, The University of Hong Kong, Hong Kong, China
  • 36 Department of Pediatric Hepatology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
  • 37 Department of Hepatobilliary Pancreatic Surgery and Liver Transplant, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
  • 38 Professor Emeritus, Chiba University, Chiba, Japan
  • 39 Department of Medicine, University of Kelaniya, Ragama, Sri Lanka
  • 40 Department of Gastroenterology, Ren Ji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
  • 41 CHESS Frontier Center, The First Hospital of Lanzhou University, Lanzhou University, Lanzhou, China
  • 42 Department of Medicine, Tokyo University School of Medicine, Tokyo, Japan
  • 43 Department of Gastroenterology and Hepatology, Faculty of Medicine, Saitama Medical University, Saitama, Japan
  • 44 New Zealand Liver Transplant Unit, Auckland Hospital, Auckland, New Zealand
  • 45 Yangon GI and Liver Centre, Pabedan, Yangon, Myanmar
  • 46 Division of Hepatology, Department of Gastroenterology and Hepatology, Chang Gung Medical Foundation, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
  • 47 Department of Liver Transplant Surgery, Dr. Rela Institute and Medical Centre, Chennai, India
  • 48 Department of Microbiology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
  • 49 Department of Pathology, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
  • 50 Department of Immunohematology and Transfusion Medicine, Institute of Liver and Biliary Sciences, New Delhi, Delhi, India
  • 51 Department of Gatroenterology, SMS Med College, Jaipur, India
  • 52 Division of Liver Transplantation and Hepatology, Manipal Hospitals, Bangalore, India
  • 53 The Liver Unit, Cochin Gastroenterology Group, Ernakulam Medical Centre, Kochi, India
  • 54 Department of Pediatric Gastroenterology, SGPGIMS, Lucknow, India
  • 55 Noora Hospital in Srinagar, Shrinagar, India
  • 56 Department of Gastroenterology and Pediatric Gastroenterology, PGIMER, Chandigarh, India
  • 57 Department of Gastroenterology and Human Nutrition, AIIMS, New Delhi, India
  • 58 Department of Gastroenterology, Hepatology and Liver Transplant, B L K Hospital, New Delhi, India
  • 59 Centre for Liver and Biliary Science, Max Hospital, New Delhi, India
  • 60 Department of Gastroenterology, Hepatology and Liver Transplant, Max Hospital, New Delhi, India
  • 61 Department of Pathology, GB Pant Hospital, New Delhi, India
  • 62 Department of Liver Transplant and Hepatobilliary Surgery, Fortis Hospital, New Delhi, India
  • 63 Department of Gastroenterology, GB Pant Hospital, New Delhi, India
  • 64 Department of Gastroenterology, Hepatology and Liver Transplant, Apollo Hospital, New Delhi, India
  • 65 Department of Hepatology, Sir H N Reliance Hospital and Research Centre, Mumbai, India
  • 66 Department of Gastroenterology and Hepatology, Narayana Hospital, Gurugram, India
  • 67 Department of Hepatology, Parimal Multi-Speciality Hospital, Ahmedabad, India
  • 68 Department of Nephrology, Institute of Liver and Biliary Sciences, New Delhi, India
  • 69 Department of Statistics and Clinical Research, Institute of Liver and Biliary Sciences, New Delhi, India
  • 70 Department of Hepatology and Gastroenterology, Kalinga Institute of Med Sciences, KIIT University, Bhubaneswar, India
  • 71 Department of Hepatology, Institute of Post Graduate Medical Education and Research, Kolkata, India
  • 72 Department of Internal Medicine, College of Medicine, The Catholic University of Korea, Seoul, South Korea
  • 73 Department Of Internal Medicine, Inje University College of Medicine, Busan, South Korea
Hepatol Int, 2019 Jul;13(4):353-390.
PMID: 31172417 DOI: 10.1007/s12072-019-09946-3

Abstract

The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. With international groups volunteering to join, the "APASL ACLF Research Consortium (AARC)" was formed in 2012, which continued to collect prospective ACLF patient data. Based on the prospective data analysis of nearly 1400 patients, the AARC consensus was published in 2014. In the past nearly four-and-a-half years, the AARC database has been enriched to about 5200 cases by major hepatology centers across Asia. The data published during the interim period were carefully analyzed and areas of contention and new developments in the field of ACLF were prioritized in a systematic manner. The AARC database was also approached for answering some of the issues where published data were limited, such as liver failure grading, its impact on the 'Golden Therapeutic Window', extrahepatic organ dysfunction and failure, development of sepsis, distinctive features of acute decompensation from ACLF and pediatric ACLF and the issues were analyzed. These initiatives concluded in a two-day meeting in October 2018 at New Delhi with finalization of the new AARC consensus. Only those statements, which were based on evidence using the Grade System and were unanimously recommended, were accepted. Finalized statements were again circulated to all the experts and subsequently presented at the AARC investigators meeting at the AASLD in November 2018. The suggestions from the experts were used to revise and finalize the consensus. After detailed deliberations and data analysis, the original definition of ACLF was found to withstand the test of time and be able to identify a homogenous group of patients presenting with liver failure. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information and areas requiring future studies are presented here.

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

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