Acute-on-chronic liver failure (ACLF): the 'Kyoto Consensus'-steps from Asia.
Santhosh E Kumar, Ananta Shrestha, Satender Pal Singh, Babu Lal Meena, Dhiraj Agrawal, Krishnadas Devadas, Mamun Al Mahtab, Harshvardhan Tevethia, Rohit Mehtani, Kamal Kajal, Amrish Sahney, Christian Strassburg, Vishwa Mohan Dayal, Moreshwar S Desai, Anand V Kulkarni, Sagnik Biswas, Madhumita Premkumar, Chandan Kumar Kedarisetty, Chhagan Bihari, Rajan Vijayaraghavan, Piyush Ranjan, Ashok Choudhury, Sanjiv Saigal, S S Hamid, Akash Shukla, Soek Siam Tan, Omesh Goyal, Manoj Sahu, V G Mohan Prasad, Kemal Fariz Kalista, Viniyendra Pamecha, Vinod Arora, Khin Maung Win, Mohd Rela, Archana Rastogi, Meenu Bajpai, Guresh Kumar, Shahinul Alam, Jin Mo Yang, Qin Ning, Michael Praktiknjo, Manoj Kumar Sharma, Ankur Jindal, Simone Strasser, Do Seon Song, Vikrant Sood, Rajeev Khanna, Subrat Kumar Acharya, Arun Valsan, P N Rao, Wasim Jafri, R K Dhiman, Debbie Shawcross, Ravi Mohanka, Nadim Mahmud, Martin Schulz, Ashish Goel, C E Eapen, Tatsuo Kanda, Abraham Koshy, Shobna Bhatia, Madunil A Niriella, Irsan Hasan, Shuichiro Shiina, Norifumi Kawada, Dong-Sik Kim, Wenyi Gu, Laurentius A Lesmana, Sadhna Lal, Harshad Devarbhavi, A S Soin, Ulrich Spengler, Yoon Jun Kim, Nobuaki Nakayama, Francois Durand, Man Fung Yuen, Pathik Parikh, Seema Alam, Bikrant Bihari Lal, Albert Chan, Sakkarin Chirapongsathorn, Cyriac Abby Philips, Shiv Kumar Sarin, Mithun Sharma, Osamu Yokosuka, J Fernandez, Puja Sakhuja, Mukul Vij, Mettu Srinivas Reddy, Andrés Cárdenas, Paolo Angeli, Shyam Kottilil, Kessarin Thanapirom, Joy Varghese, Virendra Singh, Barath Jagadisan, Jose D Sollano, K Rajender Reddy, Xiaolong Qi, Nipun Verma, Prashant Bhangui, Amar Mukund, Jennifer C Lai, Jaya Benjamin, Sunil Dadhich, Dharmesh Kapoor, Neeraj Saraf, Manav Wadhawan, Saurabh Mukewar, Dinesh Jothimani, Yogesh K Chawla, Kaushal Madan, Rakhi Maiwall, Vivek A Saraswat, Sunil Taneja, Narendra Singh Choudhary, Sanjeev Sachdeva, Manya Prasad, Anil Arora, Jaideep Behari, Yu Shi, Apichat Kaewdech, Puneet Puri, Shiran Shetty, Chen Yu, Satoshi Mochida, Tawesak Tanwandee, Anupam Kumar, Amit Goel, Vicente Arroyo, Pravin Rathi, Juan Pablo Arab, Barjesh Chander Sharma, Sudhir Maharshi, Anshu Srivastava, Zaigham Abbas, Atsushi Tanaka, Masao Omata, Audrey Coilly, Jonel Trebicka, Christian Jansen, Richard Moreau, Shikha S Sundaram, Gennaro D'Amico, Lai Wei, Suprabhat Giri, H C Lin, Anil Dhawan, Vincent Wai-Sun Wong, Surender Singh, Ajay Kumar Mishra, Patrick S Kamath, Jidong Jia, Gyongyi Szabo, Sombat Treeprasertsuk, Hai Li, Ashwani K Singal, Anoop Saraya, Ajay Duseja, Angelo Di Giorgio, Aleksander Krag, Ajay Kumar, James Fung, Mark Dhinesh Muthiah, Ashish Kumar, Vandana Midha, Ajit Sood, Sumeet Asrani, Dong Joon Kim, Ki Tae Suk, Jacob George, Paul J Thuluvath, Rohit Loomba, Mohammed Eslam, Constantine J Karvellas, Tao Chen, Seng Gee Lim, Samagra Agarwal, Jun Li, Rahul Kumar, Subhash Gupta, Sonal Asthana, Kalpana Panda, Amna Subhan Butt, Graciela Elia Castro Narro, Shweta A Singh, Charles Panackel, Lubna Kamani, Hasmik Ghazinian, Cosmas Rinaldi Adithya Lesmana, Navin Kumar Marannan, Abdul Kadir Dokmeci, Abhijeet Chowdhury, Ajay Kumar Patwa, Akash Roy, Ameet Mandot, Anil Chandra Anand, Apurva Pande, Ayaskanta Singh, Cesar Yaghi, Chang Wook Kim, Chetan R Kalal, Chien Hao Huang, Chitranshu Vasishtha, Chun Yen Lin, Diana Alcantara Payawal, Dibya Lochan Praharaj, Duan Zhongping, Fazal Karim, Gamal E Shiha, George K Lau, Girish Kumar Pati, Guan-Huei Lee, Gupse Adali, Guru Prasad Dhakal, Hari Kumar Nair, Hemamala Ilango, Hong Ling Yu, Jasmohan Bajaj, Jin Hua Hu, Jin Jun Chen, Jin Lin Hou, Johannes Chang, Jörg C Kalf, Kaiser Raja, Karan Kumar, Manal HEl Sayed, Manasa Alla, Ming Lung Yu, Mithra Prasad, Mohamed Elbasiony, Mohd Golam Azam, Necati Ormeci, Philipp Lingohr, Rino Alvani Gani, Ruveena Bhavani Rajaram, Sachin Palnitkar, Sargsyan Violeta, Shantan Venishetty, S M Shasthry, Soe Thiha Maung, Steffen Manekeller, Sudhamshu K C, Tarana Gupta, Teerha Piratvishuth, Venera Rakhmetova, Vinay Kumar Br, WRay Kim, Wong Yu Jun
Journal: Hepatology international
2025;19(1):1-69
PMID: 39961976
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.
© 2025. The Author(s).
Address:
Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.; Asian Institute of Gastroenterology Hospitals, Hyderabad, India.; Medanta-The Medicity Hospital, Gurugram, Haryana, India.; Ankara University School of Medicine, Ankara, Turkey.; Institute of Post-Graduate Medical Education and Research (IPGMER), Kolkata, West Bengal, India.; VPS Lakeshore Hospital and Research Center Ltd, Kochi, Kerala, 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), Lucknow, Uttar Pradesh, 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, Mumbai, Maharashtra, India.; Sir HN Reliance Foundation Hospital, Girgaon, Mumbai, Maharashtra, India.; Queen Mary Hospital, The University of Hong Kong, Hong Kong, China.; 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), Bhubaneshwar, Orissa, India.; King's College Hospital, London, UK.; Prince-of Song-Kla University, Songkhla, Thailand.; Fortis Hospital, Greater Noida, Uttar Pradesh, 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, USA.; Teikyo University School of Medicine, Tokyo, Japan.; Centre Hepato-Biliaire, Paul Brousse Hospital, Paris-Saclay University, Villejuif, France.; IMS and SUM Hospital, SOA University, Bhubaneswar, Odisha, India.; Saint Joseph University, Hôtel-Dieu de France University Medical Center, Beirut, Lebanon.; Gleneagles Global Hospitals, Hyderabad, Telangana, India.; The Catholic University of Korea, Seoul, Korea.; Aster Medicity, Ernakulam, Kerala, India.; Capital Medical University, Beijing, China.; Nanavati Max Super Specialty Hospital, Mumbai, Maharashtra, 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, Aluva, Kerala, India.; PACE Hospital, Hyderabad, India.; Fatima Medical University Hospital, Valenzuela Metro Manila, Philippines.; Dr. Rela Institute and Medical Centre, Chennai, India.; Hallym University, Chuncheon, Republic of Korea.; Korea University College of Medicine, Seoul, Republic of 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, Hongkong, SAR, 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, Ümraniye, Istanbul, Turkey.; Jigme Dorji Wangchuck National Referral Hospital, Thimphu, Bhutan.; Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, USA.; Taipei Veterans General Hospital, Taipei, Taiwan.; School of Medicine, Renji Hospital, Shanghai Jiao Tong University, Shanghai, China.; Ernakulam Medical Center (EMC), Kinder Multispeciality Hospital, Kochi, Kerala, India.; St. John's Medical College and Hospital, Bangalore, India.; Yerevan Medical Scientific Center, Yerevan, Armenia.; MIOT International Hospital, Chennai, India.; Dr. Cipto Mangunkusumo National General Hospital, Medical Faculty Universitas Indonesia, Jakarta, Indonesia.; 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, USA.; Virginia Commonwealth University, Richmond, VA, USA.; University of California, San Francisco, San Francisco, CA, USA.; The Fifth Medical Center of Chinese, PLA General Hospital, Beijing, China.; Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong Province, China.; Medizinische Klinik B, Universitätsklinikum Münster, Münster, Germany.; Department of Medicine, Cardinal Santos Medical Center, Manila, Philippines.; Gleneagles Global Hospital, Chennai, Tamil Nadu, 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, People's Republic of China.; University of Pennsylvania, Philadelphia, PA, USA.; King's College Hospital London, Dubai, United Arab Emirates.; Mahatma Gandhi Medical College, Jaipur, Rajasthan, 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, Thiruvananthapuram, Kerala, India.; Medistra Hospital, Jakarta, Indonesia.; Liaquat National Hospital, Karachi, Sindh, 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, USA.; 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, Ahmedabad, Gujarat, India.; Mayo Clinic College of Medicine and Science, Rochester, MN, USA.; Mercy Medical Center, Baltimore, USA.; 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.; Sir HN Reliance Foundation Hospital, Girgaon, Mumbai, Maharashtra, India.; 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, USA.; Amrita Institute of Medical Sciences and Research Centre, Faridabad, Haryana, 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, Nagpur, Maharashtra, India.; Digestive Health Institute, Children's Hospital, Aurora, CO, USA.; Kasturba Medical College, Manipal Academy of Higher Education, Manipal, Karnataka, India.; National Institute of Medical Sciences, Jaipur, India.; University of Maryland School of Medicine, Baltimore, USA.; Royal Prince Alfred Hospital, Sydney, Australia.; Selayang Hospital, University of Malaysia, Batu Caves, Selangor, Malaysia.; Aster CMI Hospital, Bengaluru, Karnataka, 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, Jaipur, Rajasthan, India.; Baylor Simmons Transplant Institute, Dallas, TX, USA.; Dr Sampuranand Medical College (SNMC), Jodhpur, Rajasthan, India.; Pandit Bhagwat Dayal Sharma Post Graduate Institute of Medical Sciences, Rohtak, Haryana, India.; Graduate School of Medical and Dental Sciences, Niigata University, Niigata, Japan.; Siriraj Hospital, Mahidol University, Bangkok, Thailand.; Astana Medical University, Astana, Kazakhstan.; European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain.; Mazumdar Shaw Medical Centre, Bangalore, Karnataka, India.; Faculty of Medicine, The Chinese University of Hong Kong, Hong Kong, China.; Punjab Institute of Liver and Biliary Sciences, Mohali, Punjab, India.; Indira Gandhi Institute of Medical Sciences, (IGIMS), Bely Road Patna, Bihar, India.; Stanford University, Stanford, CA, USA.; Medical School, Zhongda Hospital, Southeast University, Nanjing, China.; Seoul National University College of Medicine, Seoul, Republic of 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, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.
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