Acute-on-chronic liver failure (ACLF): the ‘Kyoto Consensus’—steps from Asia
Choudhury A. Kulkarni A.V. Arora V. Soin A.S. Dokmeci A.K. Chowdhury A. Koshy A. Duseja A. Kumar A. Mishra A.K. Patwa A.K. Sood A. Roy A. Shukla A. Chan A. Krag A. Mukund A. Mandot A. Goel A. Butt A.S. Sahney A. Shrestha A. Cárdenas A. Di Giorgio A. Arora A. Anand A.C. Dhawan A. Jindal A. Saraya A. Srivastava A. Kumar A. Kaewdech A. Pande A. Rastogi A. Valsan A. Goel A. Kumar A. Singal A.K. Tanaka A. Coilly A. Singh A. Meena B.L. Jagadisan B. Sharma B.C. Lal B.B. Eapen C.E. Yaghi C. Kedarisetty C.K. Kim C.W. Panackel C. Yu C. Kalal C.R. Bihari C. Huang C.H. Vasishtha C. Jansen C. Strassburg C. Lin C.Y. Karvellas C.J. Lesmana C.R.A. Philips C.A. Shawcross D. Kapoor D. Agrawal D. Payawal D.A. Praharaj D.L. Jothimani D. Song D.S. Kim D.J. Kim D.-S. Zhongping D. Karim F. Durand F. Shiha G.E. D’Amico G. Lau G.K. Pati G.K. Narro G.E.C. Lee G.-H. Adali G. Dhakal G.P. Szabo G. Lin H.C. Li H. Nair H.K. Devarbhavi H. Tevethia H. Ghazinian H. Ilango H. Yu H.L. Hasan I. Fernandez J. George J. Behari J. Fung J. Bajaj J. Benjamin J. Lai J.C. Jia J. Hu J.H. Chen J.J. Hou J.L. Yang J.M. Chang J. Trebicka J. Kalf J.C. Sollano J.D. Varghese J. Arab J.P. Li J. Reddy K.R. Raja K. Panda K. Kajal K. Kumar K. Madan K. Kalista K.F. Thanapirom K. Win K.M. Suk K.T. Devadas K. Lesmana L.A. Kamani L. Premkumar M. Niriella M.A. Al Mahtab M. Yuen M.F. Sayed M.H. Alla M. Wadhawan M. Sharma M.K. Sahu M. Prasad M. Muthiah M.D. Schulz M. Bajpai M. Reddy M.S. Praktiknjo M. Yu M.L. Prasad M. Sharma M. Elbasiony M. Eslam M. Azam M.G. Rela M. Desai M.S. Vij M. Mahmud N. Choudhary N.S. Marannan N.K. Ormeci N. Saraf N. Verma N. Nakayama N. Kawada N. OidovBaatarkhuu Goyal O. Yokosuka O. Rao P.N. Angeli P. Parikh P. Kamath P.S. Thuluvath P.J. Lingohr P. Ranjan P. Bhangui P. Rathi P. Sakhuja P. Puri P. Ning Q. Dhiman R.K. Kumar R. Vijayaraghavan R. Khanna R. Maiwall R. Mohanka R. Moreau R. Gani R.A. Loomba R. Mehtani R. Rajaram R.B. Hamid S.S. Palnitkar S. Lal S. Biswas S. Chirapongsathorn S. Agarwal S. Sachdeva S. Saigal S. Kumar S.E. Violeta S. Singh S.P. Mochida S. Mukewar S. Alam S. Lim S.G. Alam S. Shalimar Venishetty S. Sundaram S.S. Shetty S. Bhatia S. Singh S.A. Kottilil S. Strasser S. Shasthry S.M. Maung S.T. Tan S.S. Treeprasertsuk S. Asthana S. Manekeller S. Gupta S. Acharya S.K. K.C S. Maharshi S. Asrani S. Dadhich S. Taneja S. Giri S. Singh S. Chen T. Gupta T. Kanda T. Tanwandee T. Piratvishuth T. Spengler U. Prasad V.G.M. Midha V. Rakhmetova V. Arroyo V. Sood V. BR V.K. Wong V.W.-S. Pamecha V. Singh V. Dayal V.M. Saraswat V.A. Kim W. Jafri W. Gu W. Jun W.Y. Qi X. Chawla Y.K. Kim Y.J. Shi Y. Abbas Z. Kumar G. Shiina S. Wei L. Omata M. Sarin S.K.
February 2025Springer
Hepatology International
2025#19Issue 11 - 69 pp.
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.
AARC , ACLF , Acute decompensation (AD) , Cirrhosis , Non-acute decompensation (NAD) , Organ failure , Recompensation
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Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India
Asian Institute of Gastroenterology Hospitals, Hyderabad, India
Medanta-The Medicity Hospital, Haryana, Gurugram, India
Ankara University School of Medicine, Ankara, Turkey
Institute of Post-Graduate Medical Education and Research (IPGMER), West Bengal, Kolkata, India
VPS Lakeshore Hospital and Research Center Ltd, Kerala, Kochi, India
Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
Govind Ballabh Pant Hospital, New Delhi, India
Sanjay Gandhi Post Graduate Institute (SGPGI), Uttar Pradesh, Lucknow, India
King George’s Medical University, Lucknow, India
Dayanand Medical College, Ludhiana, India
Apollo Multispeciality Hospital, Kolkata, India
Seth G S Medical College and K E M Hospital, Maharashtra, Mumbai, India
Sir HN Reliance Foundation Hospital, Girgaon, Maharashtra, Mumbai, India
Queen Mary Hospital, The University of Hong Kong, Hong Kong
University of Southern Denmark, Odense, Denmark
Global Hospital, Mumbai, India
Aga Khan University Hospital, Karachi, Pakistan
BLK-Max Super Specialty Hospital, New Delhi, India
Alka Hospital, Kathmandu, Nepal
Univerity of Barcelona Institut d’Investigacions Biomèdiques August Pi-Sunyer, Barcelona, Spain
Hospital Papa Giovanni XXIII, Bergamo, Italy
Sir Ganga Ram Hospital, Rajender Nagar, New Delhi, India
Kalinga Institute of Medical Sciences (KIMS), Orissa, Bhubaneshwar, India
King’s College Hospital, London, United Kingdom
Prince-of Song-Kla University, Songkhla, Thailand
Fortis Hospital, Uttar Pradesh, Greater Noida, India
Amrita Institute of Medical Sciences and Research Centre, Amrita Vishwa Vidyapeetham, Kochi, India
Christian Medical College (CMC), Vellore, India
University of Louisville School of Medicine, Trager Transplant Center and Jewish Hospital, Louisville, KY, United States
Teikyo University School of Medicine, Tokyo, Japan
Centre Hepato-Biliaire, Paul Brousse Hospital, Paris-Saclay University, Villejuif, France
IMS and SUM Hospital, SOA University, Odisha, Bhubaneswar, India
Saint Joseph University, Hôtel-Dieu de France University Medical Center, Beirut, Lebanon
Gleneagles Global Hospitals, Telangana, Hyderabad, India
The Catholic University of Korea, Seoul, South Korea
Aster Medicity, Kerala, Ernakulam, India
Capital Medical University, Beijing, China
Nanavati Max Super Specialty Hospital, Maharashtra, Mumbai, India
Linkou Chang-Gung Memorial Hospital, Taoyuan, Taiwan
Department of Internal Medicine I, University of Bonn, Bonn, Germany
Linkou Medical Centre, Chang Gung Memorial Hospital, Keelung, Taiwan
University of Alberta, Edmonton, AB, Canada
Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia
Medistra Hospital, Jakarta, Indonesia
The Liver Institute, Rajagari Hospital, Kerala, Aluva, India
PACE Hospital, Hyderabad, India
Fatima Medical University Hospital, Valenzuela Metro Manila, Philippines
Dr. Rela Institute and Medical Centre, Chennai, India
Hallym University, Chuncheon, South Korea
Korea University College of Medicine, Seoul, South Korea
Sir Salimullah Medical College, Mitford Hospital, Dhaka, Bangladesh
Université de Paris, AP-HP, C, DMU DIGEST, Centre de Référence Des Maladies Vasculaires du Foie, FILFOIE, ERN RARE-LIVER, Centre de Recherche Sur L’inflammation, Inserm, Paris, France
Mansoura University, Mansoura, Egypt
Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello, Palermo, Italy
Clinica La Maddalena, Palermo, Italy
Humanity and Health Medical Center, SAR, Hongkong, China
Hospital Médica Sur, Mexico City, Mexico
Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubiran”,, Mexico City, Mexico
Latin-American Association for the Study of the Liver (ALEH), Santiago de Chile, Chile
National University Hospital, National University of Singapore, Singapore, Singapore
University of Health Sciences, Istanbul, Ümraniye, Turkey
Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan
Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, United States
Taipei Veterans General Hospital, Taipei, Taiwan
School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China
Ernakulam Medical Center (EMC), Kinder Multispeciality Hospital, Kerala, Kochi, India
St. John’s Medical College and Hospital, Bangalore, India
Yerevan Medical Scientific Center, Yerevan, Armenia
MIOT International Hospital, Chennai, India
University of Barcelona, IDIBAPS and CIBEREHD, Barcelona, Spain
Storr Liver Centre, Westmead Institute for Medical Research, Westmead Hospital and University of Sydney, Sydney, NSW, Australia
Pittsburgh Liver Research Center, University of Pittsburgh Medical Center, Pittsburgh, PA, United States
Virginia Commonwealth University, Richmond, VA, United States
University of California, San Francisco, San Francisco, CA, United States
The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, China
Nanfang Hospital, Southern Medical University, Guangdong Province, Guangzhou, China
Medizinische Klinik B, Universitätsklinikum Münster, Münster, Germany
Department of Medicine, Cardinal Santos Medical Center, Manila, Philippines
Gleneagles Global Hospital, Tamil Nadu, Chennai, India
Escuela de Medicina, Pontificia Universidad Católica de Chile, Santiago, Chile
Schulich School of Medicine, Western University, London, ON, Canada
The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, China
University of Pennsylvania, Philadelphia, PA, United States
King’s College Hospital London, Dubai, United Arab Emirates
Mahatma Gandhi Medical College, Rajasthan, Jaipur, India
Max Super Specialty Hospital Saket, New Delhi, India
Chulalongkorn University, Bangkok, Thailand
University of Medicine, Yangon Ministry of Health, Yangon, Myanmar
Government Medical College, Kerala, Thiruvananthapuram, India
Liaquat National Hospital, Sindh, Karachi, Pakistan
University of Kelaniya, Ragama, Sri Lanka
Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
Ain Shams University, Cairo, Egypt
Goethe University Clinic Frankfurt, Frankfurt, Germany
Kaohsiung Medical University Hospital, Kaohsiung, Taiwan
College of Medicine, National Sun Yet-Sen University, Kaohsiung, Taiwan
VGM Gastro Hospital, Coimbatore, India
Endocrine and Metabolic Disorder (BIRDEM) Shahbad, Bangladesh Institute of Research and Rehabilitation in Diabetes, Dhaka, Bangladesh
Baylor College of Medicine, Texas Children’s Hospital, Houston, TX, United States
İstanbul Health and Technology University, Istanbul, Turkey
Saitama Medical University, Iruma-Gun, Japan
Graduate School of Medicine, Osaka Metropolitan University, Osaka, Japan
Mongolian National University of Medical Sciences, Ulaanbaatar, Mongolia
Graduate School of Medicine, Chiba University, Chuo-Ku, Chiba, Japan
Department of Medicine (DIMED), University of Padova, Padua, Italy
Zydus Hospital, Gujarat, Ahmedabad, India
Mayo Clinic College of Medicine and Science, Rochester, MN, United States
Mercy Medical Center, Baltimore, United States
All India Institute of Medical Sciences (AIIMS), New Delhi, India
Topi Wala National (TN) Medical College and BYL Nair Charitable Hospital, Mumbai, India
Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
Changi General Hospital, Singapore, Singapore
European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain
Centre de Recherche Sur L’Inflammation (CRI), INSERM and Université Paris-Cité, Paris, France
Assistance Publique-Hôpitaux de Paris (APHP), Hôpital Beaujon, Service d’Hépatologie, Clichy, France
University of California, San Diego, La Jolla, CA, United States
Amrita Institute of Medical Sciences and Research Centre, Haryana, Faridabad, India
University of Malaya, Kuala Lumpur, Malaysia
Deenanath Mangeshkar Hospital and Research Centre, Pune, India
Phramongkutklao Hospital and College of Medicine, Bangkok, Thailand
Violeta Medical Centre, Yerevan, Armenia
Midas Multispeciality Hospital Pvt. Ltd, Maharashtra, Nagpur, India
Digestive Health Institute, Children’s Hospital, Aurora, CO, United States
Kasturba Medical College, Manipal Academy of Higher Education, Karnataka, Manipal, India
National Institute of Medical Sciences, Jaipur, India
University of Maryland School of Medicine, Baltimore, United States
Royal Prince Alfred Hospital, Sydney, Australia
Selayang Hospital, University of Malaysia, Batu Caves, Selangor, Malaysia
Aster CMI Hospital, Karnataka, Bengaluru, India
KIIT University, Fortis Escorts Hospital, Okhla, New Delhi, India
Bir Hospital, National Academy of Medical Sciences, Kathmandu, Nepal
Sawai Man Singh (SMS) Medical College and Hospital, Rajasthan, Jaipur, India
Baylor Simmons Transplant Institute, Dallas, TX, United States
Dr Sampuranand Medical College (SNMC), Rajasthan, Jodhpur, India
Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Haryana, Rohtak, India
Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan
Siriraj Hospital, Mahidol University, Bangkok, Thailand
Astana Medical University, Astana, Kazakhstan
Mazumdar Shaw Medical Centre, Karnataka, Bangalore, India
Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong
Punjab Institute of Liver and Biliary Sciences, Punjab, Mohali, India
Indira Gandhi Institute of Medical Sciences, (IGIMS), Bely Road Patna, Bihar, India
Stanford University, Stanford, CA, United States
Medical School, Zhongda Hospital, Southeast University, Nanjing, China
Seoul National University College of Medicine, Seoul, South Korea
Ziauddin University Hospital Karachi, Karachi, Pakistan
Juntendo University, Tokyo, Japan
Changgung Hospital, Tsinghua University, Beijing, China
Yamanashi Central Hospital, Yamanashi, Japan
Department of Hepatology
Asian Institute of Gastroenterology Hospitals
Medanta-The Medicity Hospital
Ankara University School of Medicine
Institute of Post-Graduate Medical Education and Research (IPGMER)
VPS Lakeshore Hospital and Research Center Ltd
Post Graduate Institute of Medical Education and Research (PGIMER)
Govind Ballabh Pant Hospital
Sanjay Gandhi Post Graduate Institute (SGPGI)
King George’s Medical University
Dayanand Medical College
Apollo Multispeciality Hospital
Seth G S Medical College and K E M Hospital
Sir HN Reliance Foundation Hospital
Queen Mary Hospital
University of Southern Denmark
Global Hospital
Aga Khan University Hospital
BLK-Max Super Specialty Hospital
Alka Hospital
Univerity of Barcelona Institut d’Investigacions Biomèdiques August Pi-Sunyer
Hospital Papa Giovanni XXIII
Sir Ganga Ram Hospital
Kalinga Institute of Medical Sciences (KIMS)
King’s College Hospital
Prince-of Song-Kla University
Fortis Hospital
Amrita Institute of Medical Sciences and Research Centre
Christian Medical College (CMC)
University of Louisville School of Medicine
Teikyo University School of Medicine
Centre Hepato-Biliaire
IMS and SUM Hospital
Saint Joseph University
Gleneagles Global Hospitals
The Catholic University of Korea
Aster Medicity
Capital Medical University
Nanavati Max Super Specialty Hospital
Linkou Chang-Gung Memorial Hospital
Department of Internal Medicine I
Linkou Medical Centre
University of Alberta
Dr. Cipto Mangunkusumo National General Hospital
Medistra Hospital
The Liver Institute
PACE Hospital
Fatima Medical University Hospital
Dr. Rela Institute and Medical Centre
Hallym University
Korea University College of Medicine
Sir Salimullah Medical College
Université de Paris
Mansoura University
Azienda Ospedaliera Ospedali Riuniti Villa Sofia-Cervello
Clinica La Maddalena
Humanity and Health Medical Center
Hospital Médica Sur
Instituto Nacional de Ciencias Médicas y Nutrición “Salvador Zubiran”
Latin-American Association for the Study of the Liver (ALEH)
National University Hospital
University of Health Sciences
Jigme Dorji Wangchuck National Referral Hospital
Beth Israel Deaconess Medical Center and Harvard Medical School
Taipei Veterans General Hospital
School of Medicine
Ernakulam Medical Center (EMC)
St. John’s Medical College and Hospital
Yerevan Medical Scientific Center
MIOT International Hospital
University of Barcelona
Storr Liver Centre
Pittsburgh Liver Research Center
Virginia Commonwealth University
University of California
The Fifth Medical Center of Chinese
Nanfang Hospital
Medizinische Klinik B
Department of Medicine
Gleneagles Global Hospital
Escuela de Medicina
Schulich School of Medicine
The First Affiliated Hospital
University of Pennsylvania
King’s College Hospital London
Mahatma Gandhi Medical College
Max Super Specialty Hospital Saket
Chulalongkorn University
University of Medicine
Government Medical College
Liaquat National Hospital
University of Kelaniya
Bangabandhu Sheikh Mujib Medical University
Ain Shams University
Goethe University Clinic Frankfurt
Kaohsiung Medical University Hospital
College of Medicine
VGM Gastro Hospital
Endocrine and Metabolic Disorder (BIRDEM) Shahbad
Baylor College of Medicine
İstanbul Health and Technology University
Saitama Medical University
Graduate School of Medicine
Mongolian National University of Medical Sciences
Graduate School of Medicine
Department of Medicine (DIMED)
Zydus Hospital
Mayo Clinic College of Medicine and Science
Mercy Medical Center
All India Institute of Medical Sciences (AIIMS)
Topi Wala National (TN) Medical College and BYL Nair Charitable Hospital
Tongji Medical College
Changi General Hospital
European Foundation for the Study of Chronic Liver Failure (EF CLIF)
Centre de Recherche Sur L’Inflammation (CRI)
Assistance Publique-Hôpitaux de Paris (APHP)
University of California
Amrita Institute of Medical Sciences and Research Centre
University of Malaya
Deenanath Mangeshkar Hospital and Research Centre
Phramongkutklao Hospital and College of Medicine
Violeta Medical Centre
Midas Multispeciality Hospital Pvt. Ltd
Digestive Health Institute
Kasturba Medical College
National Institute of Medical Sciences
University of Maryland School of Medicine
Royal Prince Alfred Hospital
Selayang Hospital
Aster CMI Hospital
KIIT University
Bir Hospital
Sawai Man Singh (SMS) Medical College and Hospital
Baylor Simmons Transplant Institute
Dr Sampuranand Medical College (SNMC)
Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences
Graduate School of Medical and Dental Sciences
Siriraj Hospital
Astana Medical University
Mazumdar Shaw Medical Centre
Faculty of Medicine
Punjab Institute of Liver and Biliary Sciences
Indira Gandhi Institute of Medical Sciences
Stanford University
Medical School
Seoul National University College of Medicine
Ziauddin University Hospital Karachi
Juntendo University
Changgung Hospital
Yamanashi Central Hospital
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