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

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

doi:10.1007/s12072-014-9580-2

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. 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.

Highlights

Liver failure is a common medical ailment, and its incidence is increasing with the use of alcohol and growing epidemic of obesity and diabetes
It can present as acute liver failure (ALF), acute-on-chronic liver failure (ACLF), or an acute decompensation of an end-stage liver disease
2.2 Chronic hepatitis and/or significant fibrosis without cirrhosis should be taken as a chronic liver disease, if such a patient presents as ACLF (1b, C)

Summary

Introduction

Liver failure is a common medical ailment, and its incidence is increasing with the use of alcohol and growing epidemic of obesity and diabetes. These patients grouped together as acute-on-chronic liver failure (ACLF) have a poor outcome. The AARC data, based on the liver biopsy studies, corroborated the facts that a fair proportion of patients with ACLF do not have underlying cirrhosis, but still carry a poor prognosis, with mortality above 33 % at 4 weeks.

Results

Conclusion