Falla hepatica

ACUTE ON CHRONIC LIVER FAILURE (ACLF): CONSENSUS RECOMMENDATIONS OF THE ASIAN PACIFIC ASSOCIATION FOR THE STUDY OF THE LIVER (APASL)

Shiv Kumar Sarin, Ashish Kumar, John Almeida, Yogesh Kumar Chawla, Sheung Tat Fan, Hitendra Garg, H Janaka de Silva, Saeed Hamid, Rajiv Jalan, Piyawat Komolmitr, George K Lau, Qing Liu, Kaushal Madan, Rosmawati Mohamed, Qin Ning, Salimur Rahman, Archana Rastogi,Stephen M Riordan, Puja Sakhuja, Didier Samuel, Samir Shah, Barjesh Chander Sharma, Praveen Sharma, Yasuhiro Takikawa, Babu Ram Thapa, Chun Tao Wai, Man-Fung Yuen (APASL Working Party on ACLF) Running title: ACLF: The APASL Recommendations

Correspondence: Dr S K Sarin, MD, DM Department of Gastroenterology G B Pant Hospital, Affiliated to University of Delhi New Delhi – 110 002, India Phone:+91-11-23232013 Fax: +91-11-23219710 E-mail:sksarin@nda.vsnl.net.in

ABSTRACT The Asian Pacific Association for the Study of the Liver (APASL) set up a Working Party on Acute on Chronic Liver Failure (ACLF) in 2004, with a mandate to develop consensus guidelines on various aspects of ACLF relevant to disease patterns and clinical practice in the Asia-Pacific region. Experts predominantly from theAsia-Pacific region constituted this Working Party and were requested to identify different issues of ACLF and develop the consensus guidelines. A 2-day meeting of the Working Party was held on January 22-23, 2008, at New Delhi, India, to discuss and finalize the consensus statements. Only those statements that were unanimously approved by the experts were accepted. These statements werecirculated to all the experts and were subsequently presented at the Annual Conference of the APASL at Seoul, Korea in March 2008. The consensus statements along with relevant background information are presented in this review.

INTRODUCTION Liver failure can develop either as acute liver failure (in the absence of any pre-existing liver disease), as acute on chronic liver failure (ACLF) (an acutedeterioration of known or unknown chronic liver disease), or as a chronic decompensation of an end-stage liver disease. There is limited data on the entity of ACLF and there are no consensus guidelines on its definition, diagnosis, and management. The Asian Pacific Association for the Study of the Liver (APASL) set up a Working Party on ACLF in 2004 with a mandate to study and analyze the variousaspects of this clinical entity and to develop consensus guidelines on ACLF relevant to the disease pattern and clinical practice. Experts from all over the globe, especially from the Asia-Pacific region constituted this Working Party and were requested to identify different issues of ACLF and develop the consensus guidelines. The process for the development of these consensus guidelines containedthe following steps: review of all available published literature on ACLF; an effort to define the acute hepatic insults, the underlying chronic liver disease, and the liver failure of ACLF; a survey of the current approaches for the diagnosis and management of ACLF; discussion on contentious issues; and deliberations to prepare the consensus statement by the experts of the Working Party. A 2-daymeeting was held on January 22-23, 2008, at New Delhi, India, to discuss and finalize the recommendations and guidelines. Only those statements that were unanimously approved by the experts were accepted. These statements were circulated to all the experts, posted on the ACLF website (www.aclf.in) and were subsequently finalized. The Working Party adopted the Oxford System [1] of evidence-basedapproach for developing the consensus statements. The group assessed the level of existing evidence and accordingly ranked the

recommendations (i.e., level of evidence from 1 [highest] to 5 [lowest]; grade of recommendation from A [strongest] to D [weakest]). The consensus statements are presented in this review. A brief background note has been added to explain in more detail the genesis of the...