Acute-on-chronic liver failure (ACLF): the ‘Kyoto Consensus’—steps from Asia
Authors: Choudhury Ashok , Kulkarni Anand V. , Arora Vinod , Soin A. S. , Dokmeci Abdul Kadir , Chowdhury Abhijeet , Koshy Abraham , Duseja Ajay , Kumar Ajay , Mishra Ajay Kumar , Patwa Ajay Kumar , Sood Ajit , Roy Akash , Shukla Akash , Chan Albert , Krag Aleksander , Mukund Amar , Mandot Ameet , Goel Amit , Butt Amna Subhan , Sahney Amrish , Shrestha Ananta , Cárdenas Andrés , Di Giorgio Angelo , Arora Anil , Anand Anil Chandra , Dhawan Anil , Jindal Ankur , Saraya Anoop , Srivastava Anshu , Kumar Anupam , Kaewdech Apichat , Pande Apurva , Rastogi Archana , Valsan Arun , Goel Ashish , Kumar Ashish , Singal Ashwani K. , Tanaka Atsushi , Coilly Audrey , Singh Ayaskanta , Meena Babu Lal , Jagadisan Barath , Sharma Barjesh Chander , Lal Bikrant Bihari , Eapen C. E. , Yaghi Cesar , Kedarisetty Chandan Kumar , Kim Chang Wook , Panackel Charles , Yu Chen , Kalal Chetan R. , Bihari Chhagan , Huang Chien Hao , Vasishtha Chitranshu , Jansen Christian , Strassburg Christian , Lin Chun Yen , Karvellas Constantine J. , Lesmana Cosmas Rinaldi Adithya , Philips Cyriac Abby , Shawcross Debbie , Kapoor Dharmesh , Agrawal Dhiraj , Payawal Diana Alcantara , Praharaj Dibya Lochan , Jothimani Dinesh , Song Do Seon , Kim Dong Joon , Kim Dong-Sik , Zhongping Duan , Karim Fazal , Durand Francois , Shiha Gamal E. , D’Amico Gennaro , Lau George K. , Pati Girish Kumar , Narro Graciela Elia Castro , Lee Guan-Huei , Adali Gupse , Dhakal Guru Prasad , Szabo Gyongyi , Lin H. C. , Li Hai , Nair Hari Kumar , Devarbhavi Harshad , Tevethia Harshvardhan , Ghazinian Hasmik , Ilango Hemamala , Yu Hong Ling , Hasan Irsan , Fernandez J. , George Jacob , Behari Jaideep , Fung James , Bajaj Jasmohan , Benjamin Jaya , Lai Jennifer C. , Jia Jidong , Hu Jin Hua , Chen Jin Jun , Hou Jin Lin , Yang Jin Mo , Chang Johannes , Trebicka Jonel , Kalf Jörg C. , Sollano Jose D. , Varghese Joy , Arab Juan Pablo , Li Jun , Reddy K. Rajender , Raja Kaiser , Panda Kalpana , Kajal Kamal , Kumar Karan , Madan Kaushal , Kalista Kemal Fariz , Thanapirom Kessarin , Win Khin Maung , Suk Ki Tae , Devadas Krishnadas , Lesmana Laurentius A. , Kamani Lubna , Premkumar Madhumita , Niriella Madunil A. , Al Mahtab Mamun , Yuen Man Fung , Sayed Manal HEl , Alla Manasa , Wadhawan Manav , Sharma Manoj Kumar , Sahu Manoj , Prasad Manya , Muthiah Mark Dhinesh , Schulz Martin , Bajpai Meenu , Reddy Mettu Srinivas , Praktiknjo Michael , Yu Ming Lung , Prasad Mithra , Sharma Mithun , Elbasiony Mohamed , Eslam Mohammed , Azam Mohd. Golam , Rela Mohd. , Desai Moreshwar S. , Vij Mukul , Mahmud Nadim , Choudhary Narendra Singh , Marannan Navin Kumar , Ormeci Necati , Saraf Neeraj , Verma Nipun , Nakayama Nobuaki , Kawada Norifumi , Oidov Baatarkhuu  , Goyal Omesh , Yokosuka Osamu , Rao P. N. , Angeli Paolo , Parikh Pathik , Kamath Patrick S. , Thuluvath Paul J. , Lingohr Philipp , Ranjan Piyush , Bhangui Prashant , Rathi Pravin , Sakhuja Puja , Puri Puneet , Ning Qin , Dhiman R. K. , Kumar Rahul , Vijayaraghavan Rajan , Khanna Rajeev , Maiwall Rakhi , Mohanka Ravi , Moreau Richard , Gani Rino Alvani , Loomba Rohit , Mehtani Rohit , Rajaram Ruveena Bhavani , Hamid S. S. , Palnitkar Sachin , Lal Sadhna , Biswas Sagnik , Chirapongsathorn Sakkarin , Agarwal Samagra , Sachdeva Sanjeev , Saigal Sanjiv , Kumar Santhosh E. , Violeta Sargsyan , Singh Satender Pal , Mochida Satoshi , Mukewar Saurabh , Alam Seema , Lim Seng Gee , Alam Shahinul , Shalimar  , Venishetty Shantan , Sundaram Shikha S. , Shetty Shiran , Bhatia Shobna , Singh Shweta A. , Kottilil Shyam , Strasser Simone , Shasthry S. M. , Maung Soe Thiha , Tan Soek Siam , Treeprasertsuk Sombat , Asthana Sonal , Manekeller Steffen , Gupta Subhash , Acharya Subrat Kumar , K.C. Sudhamshu , Maharshi Sudhir , Asrani Sumeet , Dadhich Sunil , Taneja Sunil , Giri Suprabhat , Singh Surender , Chen Tao , Gupta Tarana , Kanda Tatsuo , Tanwandee Tawesak , Piratvishuth Teerha , Spengler Ulrich , Prasad V. G. Mohan , Midha Vandana , Rakhmetova Venera , Arroyo Vicente , Sood Vikrant , BR Vinay Kumar , Wong Vincent Wai-Sun , Pamecha Viniyendra , Singh Virendra , Dayal Vishwa Mohan , Saraswat Vivek A. , Kim WRay , Jafri Wasim , Gu Wenyi , Jun Wong Yu , Qi Xiaolong , Chawla Yogesh K. , Kim Yoon Jun , Shi Yu , Abbas Zaigham , Kumar Guresh , Shiina Shuichiro , Wei Lai , Omata Masao , Sarin Shiv Kumar ,   APASL-ACLF Research Consortium (AARC) for APASL-ACLF working party
Published: February 2025

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.