Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the Study of the Liver (APASL) 2014

Shiv Kumar Sarin, Chandan Kumar Kedarisetty, Zaigham Abbas, Deepak Amarapurkar, Chhagan Bihari, Albert C. Chan, Yogesh Kumar Chawla, A. Kadir Dokmeci, Hitendra Garg, Hasmik Ghazinyan, Saeed Hamid, Dong Joon Kim, Piyawat Komolmit, Suman Lata, Guan Huei Lee, Laurentius A. Lesmana, Mamun Mahtab, Rakhi Maiwall, Richard Moreau, Qin Ning, Viniyendra Pamecha, Diana Alcantara Payawal, Archana Rastogi, Salimur Rahman, Mohamed Rela, Anoop Saraya, Didier Samuel, Vivek Saraswat, Samir Shah, Gamal Shiha, Brajesh Chander Sharma, Manoj Kumar Sharma, Kapil Sharma, Amna Subhan Butt, Soek Siam Tan, Chitranshu Vashishtha, Zeeshan Ahmed Wani, Man-Fung Yuen, Osamu Yokosuka, the APASL ACLF Working Party

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. Due to the rapid advancements in the knowledge and available information, a consortium of members from countries across Asia Pacific, "APASL ACLF Research Consortium (AARC)," was formed in 2012. A large cohort of retrospective and prospective data of ACLF patients was collated and followed up in this data base. The current ACLF definition was reassessed based on the new AARC data base. These initiatives were concluded on a 2-day meeting in February 2014 at New Delhi and led to the development of the final AARC consensus. Only those statements which were based on the evidence and were unanimously recommended were accepted. These statements were circulated again to all the experts and subsequently presented at the annual conference of the APASL at Brisbane, on March 14, 2014. The suggestions from the delegates were analyzed by the expert panel, and the modifications in the consensus were made. The final consensus and guidelines document was prepared. After detailed deliberations and data analysis, the original proposed definition was found to withstand the test of time and identify a homogenous group of patients presenting with liver failure. Based on the AARC data, liver failure grading, and its impact on the "Golden therapeutic Window," extra-hepatic organ failure and development of sepsis were analyzed. 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 are presented here.