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    Acute-on-chronic liver failure (ACLF): The ‘Kyoto consensus’-steps from Asia
    (Springer, 2025) Choudhury, Ashok; Kulkarni, Anand V.; Arora, Vinod; Sood, Ajit; Dökmeci, Abdul Kadir; Chowdhury, Abhijeet; Koshy, Abraham; Duseja, Ajay; Örmeci, Necati; Mishra, Ajay Kumar
    Acute-on-chronic liver failure (ACLF) is a condition associated with high mortality in the absence of liver transplanta tion. There have been various defnitions proposed worldwide. The frst consensus report of the working party of the Asian Pacifc 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–Pacifc 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 defnitions to be equally efective in their respective cohorts in identifying patients with high mortality. To overcome the diferences 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 feld 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 fnal recommendations along with the relevant background information and areas requiring future studies.
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    Non‑cirrhotic portal fibrosis/idiopathic portal hypertension: APASL recommendations for diagnosis and management
    (Springer Nature, 2024) Shukla, Akash; Rockey, Don C.; Kamath, Patrick S.; Kleiner, David E.; Singh, Ankita; Vaidya, Arun; Koshy, Abraham; Goel, Ashish; Dökmeci, A. Kadir; Meena, Babulal; Philips, Cyriac Abby; Sharma, Chhagan Bihari; Örmeci, Necati; Sarin, Shiv Kumar
    Since the Asian Pacific Association for the Study of the Liver (APASL) published guidelines on non-cirrhotic portal fibrosis/idiopathic portal hypertension in 2007, there has been a surge in new information, especially with the introduction of the term porto-sinusoidal vascular disorder (PSVD). Non-cirrhotic intra-hepatic causes of portal hypertension include disorders with a clearly identifiable etiology, such as schistosomiasis, as well as disorders with an unclear etiology such as non-cirrhotic portal fibrosis (NCPF), also termed idiopathic portal hypertension (IPH). This entity is being increasingly recognized as being associated with systemic disease and drug therapy, especially cancer therapy. An international working group with extensive expertise in portal hypertension was assigned with formulating consensus guidelines to clarify the definition, diagnosis, histological features, natural history, and management of NCPF/IPH, especially in the context of PSVD. The guidelines were prepared based on evidence from existing published literature. Whenever there was paucity of evidence, expert opinion was included after detailed deliberation. The goal of this manuscript, therefore, is to enhance the current understanding and help create global consensus on the issues surrounding NCPF/IPH.
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    The global ACLF consensus : The ‘Istanbul document’
    (Springer Nature Link, 2026) Kulkarni, Anand V.; Choudhury, Ashok; Arora, Vinod; Dökmeci, Abdul Kadir; Koshy, Abraham; Gürakar, Ahmet; Duseja, Ajay; Roy, Akash; Örmeci, Necati; Sarin, Shiv Kumar
    The Kyoto Consensus introduced a key conceptual shift in characterizing acute-on-chronic liver failure (ACLF) patients into Type-A and Type-B phenotypes. A day-long meeting was convened at Istanbul during APASL 2026 to assess the real-world applicability of Type-A and Type-B ACLF across continents. The objective was that physicians could recognize ACLF as a unified disease entity, and quality research and new therapeutic options with defined end-points could be undertaken. Data from APASL ACLF Research Consortium (AARC), EASL-CLIF and NACSELD were assessed and discussed in detail. While the applicability of Type-A and Type-B varied across cohorts, the definition required to be appended. The experts unanimously agreed that ‘liver failure’ as identified by serum bilirubin of≥5 mg/dl and INR≥1.5 should be the ‘core’ for both Type-A and Type-B ACLF. Type-A ACLF is considered when “a patient with compensated advanced chronic liver disease or compensated cirrhosis presents with index decompensation as liver failure followed by development of ascites and/ or hepatic encephalopathy within 4 weeks.” Type-B ACLF is considered when “a patient with prior or concurrent decompensated cirrhosis presents with acute decompensation as liver failure accompanied by one or more extrahepatic organ failures.” New definitions of organ dysfunction and failure, as well as endpoints for clinical trials, were also deliberated and finalized. The “Istanbul Report”, presents a milestone evidence based consensus document carrying harmonization of various aspects of ACLF, incorporating current evidence, critically analyzed unanimous recommendations, and key areas for future studies.