Acute-on-chronic liver failure (ACLF): the ‘Kyoto Consensus’—steps from Asia
Ashok Choudhury, Anand V. Kulkarni, Vinod Arora, Arvinder Singh Soin, A. Kadir Dökmeci, Abhijeet Chowdhury, Abraham Koshy, Ajay Duseja, Ajay Kumar, Ajay Mishra, Ajay Kumar Patwa, Ajit Sood, Akash Roy, Akash Shukla, Albert Chan, Aleksander Krag, Amar Mukund, Ameet Mandot, Amit Goel, Amna Subhan Butt, Amrish Sahney, Ananta Shrestha, Andrés Cárdenas, Angelo Di Giorgio, Anil Arora, Anil C. Anand, Anil Dhawan, Ankur Jindal, Anoop Saraya, Anshu Srivastava, Anupam Kumar, Apichat Kaewdech, Apurva Pande, Archana Rastogi, Arun Valsan, Ashish Goel, Ashish Kumar, Ashwani K. Singal, Atsushi Tanaka, Audrey Coilly, Ayaskanta Singh, Babu Lal Meena, Barath Jagadisan, Barjesh Chander Sharma, Bikrant Bihari Lal, C. E. Eapen, César Yaghi, Chandan Kumar Kedarisetty, Chang Wook Kim, Charles Panackel, Yu Chen, Chetan R. Kalal, Chhagan Bihari, Chien Huang, Chitranshu Vasishtha, Christian Jansen, Christian Strassburg, Chun Yen Lin, Constantine Karvellas, Cosmas Rinaldi Adithya Lesmana, Cyriac Abby Philips, Debbie L. Shawcross, Dharmesh Kapoor, Dhiraj Agrawal, Diana A. Payawal, Dibya Lochan Praharaj, Dinesh Jothimani, Do Seon Song, Dong Joon Kim, Dong‐Sik Kim, Zhongping Duan, Fazal Karim, François Durand, Gamal Shiha, Gennaro D’Amico, George Lau, Girish Kumar Pati, Graciela Castro‐Narro, Guan Huei Lee, Gupse Adalı, Guru Prasad Dhakal, Gyöngyi Szabó, Hui‐Ching Lin, Hai Li, Harikumar R. Nair, Harshad Devarbhavi, Harsh Vardhan Tevethia, Hasmik Ghazinian, Hemamala Ilango, Hong Yu, Irsan Hasan, J. Fernández, Jacob George, Jaideep Behari, James Fung, Jasmohan S. Bajaj, Jaya Benjamin, Jennifer C. Lai, Jidong Jia, Jin Hua Hu
Abstract
Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplantation. There have been various definitions proposed worldwide. The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set in 2004 on ACLF was published in 2009, and the "APASL ACLF Research Consortium (AARC)" was formed in 2012. The AARC database has prospectively collected nearly 10,500 cases of ACLF from various countries in the Asia-Pacific region. This database has been instrumental in developing the AARC score and grade of ACLF, the concept of the 'Golden Therapeutic Window', the 'transplant window', and plasmapheresis as a treatment modality. Also, the data has been key to identifying pediatric ACLF. The European Association for the Study of Liver-Chronic Liver Failure (EASL CLIF) and the North American Association for the Study of the End Stage Liver Disease (NACSELD) from the West added the concepts of organ failure and infection as precipitants for the development of ACLF and CLIF-Sequential Organ Failure Assessment (SOFA) and NACSELD scores for prognostication. The Chinese Group on the Study of Severe Hepatitis B (COSSH) added COSSH-ACLF criteria to manage hepatitis b virus-ACLF with and without cirrhosis. The literature supports these definitions to be equally effective in their respective cohorts in identifying patients with high mortality. To overcome the differences and to develop a global consensus, APASL took the initiative and invited the global stakeholders, including opinion leaders from Asia, EASL and AASLD, and other researchers in the field of ACLF to identify the key issues and develop an evidence-based consensus document. The consensus document was presented in a hybrid format at the APASL annual meeting in Kyoto in March 2024. The 'Kyoto APASL Consensus' presented below carries the final recommendations along with the relevant background information and areas requiring future studies.