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Editorial
. 2019 Jul;13(4):353-390.
doi: 10.1007/s12072-019-09946-3. Epub 2019 Jun 6.

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

Shiv Kumar Sarin  1 , Ashok Choudhury  2 , Manoj K Sharma  2 , Rakhi Maiwall  2 , Mamun Al Mahtab  3 , Salimur Rahman  3 , Sanjiv Saigal  4 , Neeraj Saraf  4 , A S Soin  4 , Harshad Devarbhavi  5 , Dong Joon Kim  6 , R K Dhiman  7 , Ajay Duseja  7 , Sunil Taneja  7 , C E Eapen  8 , Ashish Goel  8 , Q Ning  9 , Tao Chen  10 , Ke Ma  9 , Z Duan  10 , Chen Yu  10 , Sombat Treeprasertsuk  11 , S S Hamid  12 , Amna S Butt  12 , Wasim Jafri  12 , Akash Shukla  13 , Vivek Saraswat  14 , Soek Siam Tan  15 , Ajit Sood  16 , Vandana Midha  16 , Omesh Goyal  16 , Hasmik Ghazinyan  17 , Anil Arora  18 , Jinhua Hu  19 , Manoj Sahu  20 , P N Rao  21 , Guan H Lee  22 , Seng G Lim  22 , Laurentius A Lesmana  23 , Cosmas Rinaldi Lesmana  23 , Samir Shah  24 , V G Mohan Prasad  25 , Diana A Payawal  26 , Zaigham Abbas  27 , A Kadir Dokmeci  28 , Jose D Sollano  29 , Gian Carpio  29 , Ananta Shresta  30 , G K Lau  31 , Md Fazal Karim  32 , Gamal Shiha  33 , Rino Gani  34 , Kemal Fariz Kalista  34 , Man-Fung Yuen  35 , Seema Alam  36 , Rajeev Khanna  36 , Vikrant Sood  36 , Bikrant Bihari Lal  36 , Viniyendra Pamecha  37 , Ankur Jindal  2 , V Rajan  2 , Vinod Arora  2 , Osamu Yokosuka  38 , Madunil A Niriella  39 , Hai Li  40 , Xiaolong Qi  41 , Atsushi Tanaka  42 , Satoshi Mochida  43 , Dominic Ray Chaudhuri  44 , Ed Gane  44 , Khin Maung Win  45 , Wei Ting Chen  46 , Mohd Rela  47 , Dharmesh Kapoor  24 , Amit Rastogi  4 , Pratibha Kale  48 , Archana Rastogi  49 , Chhagan Bihari Sharma  49 , Meenu Bajpai  50 , Virender Singh  7 , Madhumita Premkumar  7 , Sudhir Maharashi  51 , A Olithselvan  52 , Cyriac Abby Philips  53 , Anshu Srivastava  54 , Surender K Yachha  54 , Zeeshan Ahmad Wani  55 , B R Thapa  56 , Anoop Saraya  57 , Shalimar  57 , Ashish Kumar  18 , Manav Wadhawan  58 , Subash Gupta  59 , Kaushal Madan  60 , Puja Sakhuja  61 , Vivek Vij  62 , Barjesh C Sharma  63 , Hitendra Garg  64 , Vishal Garg  64 , Chetan Kalal  65 , Lovkesh Anand  66 , Tanmay Vyas  67 , Rajan P Mathur  68 , Guresh Kumar  69 , Priyanka Jain  69 , Samba Siva Rao Pasupuleti  69 , Yogesh K Chawla  70 , Abhijit Chowdhury  71 , Shahinul Alam  3 , Do Seon Song  72 , Jin Mo Yang  72 , Eileen L Yoon  73 ; APASL ACLF Research Consortium (AARC) for APASL ACLF working Party.
Affiliations
Editorial

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

Shiv Kumar Sarin et al. Hepatol Int. 2019 Jul.

Erratum in

  • Correction to: Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update.
    Sarin SK, Choudhury A, Sharma MK, Maiwall R, Al Mahtab M, Rahman S, Saigal S, Saraf N, Soin AS, Devarbhavi H, Kim DJ, Dhiman RK, Duseja A, Taneja S, Eapen CE, Goel A, Ning Q, Chen T, Ma K, Duan Z, Yu C, Treeprasertsuk S, Hamid SS, Butt AS, Jafri W, Shukla A, Saraswat V, Tan SS, Sood A, Midha V, Goyal O, Ghazinyan H, Arora A, Hu J, Sahu M, Rao PN, Lee GH, Lim SG, Lesmana LA, Lesmana CR, Shah S, Prasad VGM, Payawal DA, Abbas Z, Dokmeci AK, Sollano JD, Carpio G, Shresta A, Lau GK, Fazal Karim M, Shiha G, Gani R, Kalista KF, Yuen MF, Alam S, Khanna R, Sood V, Lal BB, Pamecha V, Jindal A, Rajan V, Arora V, Yokosuka O, Niriella MA, Li H, Qi X, Tanaka A, Mochida S, Chaudhuri DR, Gane E, Win KM, Chen WT, Rela M, Kapoor D, Rastogi A, Kale P, Rastogi A, Sharma CB, Bajpai M, Singh V, Premkumar M, Maharashi S, Olithselvan A, Philips CA, Srivastava A, Yachha SK, Wani ZA, Thapa BR, Saraya A, Shalimar, Kumar A, Wadhawan M, Gupta S, Madan K, Sakhuja P, Vij V, Sharma BC, Garg H, Garg V, Kalal C, Anand L, Vyas T, Mathur RP, Kumar G, Jain P, Pasupuleti SSR, Chawla YK, Chowdhury A, Alam S, Song DS, Yang JM, Yoon EL; APASL ACLF Research Consortium (AARC) for APASL ACLF working Party.. Sarin SK, et al. Hepatol Int. 2019 Nov;13(6):826-828. doi: 10.1007/s12072-019-09980-1. Epub 2019 Oct 9. Hepatol Int. 2019. PMID: 31595462 Free PMC article.

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.

Keywords: AARC; ALF; Acute decompensation; Alcoholic liver disease; Chronic liver disease; Cirrhosis; Decompensation; Jaundice; Liver failure.

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Conflict of interest statement

Shiv Kumar Sarin et al. declare that they have no conflict of interest.

Figures

Fig. 1
Fig. 1
Concept of ACLF and the cohorts included in different definitions. The figure describes the response of the liver to an acute hepatic injury, depending on the underlying hepatic injury, prior decompensation, time frame from insult to presentation with decompensation and reversibility with mitigation of the acute insult. The spectrum extends from acute liver failure, acute-on-chronic liver failure, acute decompensation, end-stage liver disease. ACLF is distinct like ALF when the APASL definition is considered. APASL definition is simple and homogenous and is distinct
Fig. 2
Fig. 2
Sequence of events in Diagnostic Criteria of ACLF: East vs. West. The figure clearly describes the sequence of organ failure and its mechanism. An acute hepatic insult leading to hepatic decompensation is the driver and subsequent extrahepatic organ failure is due to failure of recovery/regeneration and development of sepsis after a Golden Window. With consideration of sepsis as the intiating factor and development of extrahepatic organ involvement as a part of definition leads to late identification of the ACLF patients where the therapeutic windos is lost. The difference between ACLF, AD and ESLD (as in Fig. 1) is blurred and entity is heterogenous. So pure hepatic insult leading to hepatic failure at the beginning and subsequent extrahepatic organ failure as complication, not defining complex is the crux in managing this group of liver disease patient
Fig. 3
Fig. 3
Golden window in ACLF. ACLF is the state of acute inflammatory response with cytokine burst. The SIRS is a response to this inflammation and subsequent resolution of inflammation and recovery or persistence of inflammation (leading to Compensatory Anti-inflammatory Inflammatory Response Syndrome-CARS) and sepsis. Patients of ACLF in a period of 7 days develop SIRS (which can be infective or sterile) but both the things lead to complications and sepsis develops subsequently. This time period is the therapeutic Golden Window. SIRS needs consideration for organ support, antibiotics for occult sepsis and prioritization for definitive therapy, i.e., liver transplant
Fig. 4
Fig. 4
Algorithm for management of ACLF. The algorithmic approach to ACLF is highlighted based on the severity of liver failure, acute etiology and specific therapy and dynamic disease course. The specific treatment initiated, but if the disease severity is more, i.e., AARC Score (consideration of bilirubin, creatinine, INR, lactate and HE grade) 11 or more the response is poor with best medical supportive car; hence, early consideration for liver transplant should be done, whereas other group needs to be seen for 4–7 days with specific therapy and standard medical therapy. Any deterioration or AARC score 11 or more needs to consider LT. The presence of extrahepatic organ failure needs to be managed, and optimization and improvement need to be correlated with over all recovery else poor prognoses to be considered
Fig. 5
Fig. 5
Comparison of AARC score against other disease severity score
See this image and copyright information in PMC

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References

    1. Sarin SK, Chandan K, Zaigham A, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL) Hepatol Int. 2014;8:453–471. doi: 10.1007/s12072-014-9580-2. - DOI - PubMed
    1. Sarin SK, Kumar A, et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL) Hepatol Int. 2009;3(269):282. - PMC - PubMed
    1. Choudhury A., Jindal A., Maiwall R., Sharma M. K., Sharma B. C., Pamecha V., Mahtab M., Rahman S., Chawla Y. K., Taneja S., Tan S. S., Devarbhavi H., Duan Z., Yu Chen, Ning Q., Jia Ji Dong, Amarapurkar D., Eapen C. E., Goel A., Hamid S. S., Butt A. S., Jafri W., Kim D. J., Ghazinian H., Lee G. H., Sood Ajit, Lesmana L. A., Abbas Z., Shiha G., Payawal D. A., Dokmeci A. K., Sollano J. D., Carpio G., Lau G. K., Karim F., Rao P. N., Moreau R., Jain P., Bhatia P., Kumar G., Sarin S. K. Liver failure determines the outcome in patients of acute-on-chronic liver failure (ACLF): comparison of APASL ACLF research consortium (AARC) and CLIF-SOFA models. Hepatology International. 2017;11(5):461–471. doi: 10.1007/s12072-017-9816-z. - DOI - PubMed
    1. Atkins D, Best D, Briss PA, et al. Grading quality of evidence and strength of recommendations. BMJ. 2004;328:1490. doi: 10.1136/bmj.328.7454.1490. - DOI - PMC - PubMed
    1. O’Grady JG, Schalm SW, Williams R. Acute liver failure: redefining the syndromes. Lancet. 1993;342:273–275. doi: 10.1016/0140-6736(93)91818-7. - DOI - PubMed

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