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Background and aims <p>Acute-on-chronic liver failure (ACLF) is a severe syndrome in patients with chronic liver disease, marked by rapid multi-organ failure and high short-term mortality. Managing ACLF requires intensive care, but standardized global guidelines were previously lacking. The APASL ACLF Research Consortium (AARC) developed this position paper to establish a unified, evidence-based consensus for its critical care management.</p> Methods <p>A global collaboration of 109 experts employed a systematic methodology to address key aspects of ACLF care. Sections were drafted by specialist teams, with recommendations developed using the GRADE system. Draft statements underwent iterative review and refinement, followed by an expert panel consensus process consisting of open show-of-hands voting during the APASL Annual Conference in March 2025 in Beijing and a subsequent anonymous online voting round.</p> Results <p>The consensus delivers 104 position statements. Key recommendations include using prognostic scores (AARC, CLIF-C ACLF, GIC) for ICU transfer and treatment decisions, and aggressively managing precipitating factors or complications like infections. It details organ-specific support for liver, kidney, and brain failure, advocating for early, targeted antibiotics and careful fluid management. The role of bridging therapies (plasma exchange, artificial liver systems) and nutritional support is emphasized. For transplantation, the guidelines provide criteria for patient selection and timing, particularly for alcohol-related ACLF.</p> Conclusions <p>The APASL ACLF Beijing Position Paper provides a comprehensive, standardized framework for managing critically sick ACLF patients. Integrating multidisciplinary expertise and current evidence, these guidelines aim to optimize care, inform clinical decisions, and improve survival for this high-risk population. As a few recommendations are supported predominantly by data from different continents, they should therefore be interpreted in local contexts.</p>

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A global consensus on the critical care management of acute-on-chronic liver failure patients: the APASL ACLF Beijing Position Paper

  • 期刊论文

  • 发表日期：

    2026年7月30日

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  • Tao Chen,
  • Ashok Choudhury,
  • Wei Liu,
  • Meng Zhang,
  • Wenhui Wu,
  • Huiling Xiang,
  • Xiaojing Wang,
  • Zaigham Abbas,
  • Tatsuo Kanda,
  • Ramazan Idilman,
  • Kemal Fariz Kalista,
  • Hai Li,
  • Rosmawati Binti Mohamed,
  • Paolo Angeli,
  • Mohamed Elbasiony,
  • Hasitha S. Wijewantha,
  • Charles Panackel,
  • Kessarin Thanapirom,
  • Ashwani K. Singal,
  • Khin Maung Win,
  • Debbie L. Shawcross,
  • Elliot B. Tapper,
  • Ananta Shrestha,
  • Jonel Trebicka,
  • Abdul Kadir Dokmeci,
  • Aleksander Krag,
  • Anand V. Kulkarni,
  • Jinhua Hu,
  • Haibin Su,
  • Gupse Adali,
  • Rahul Kumar,
  • George K. Lau,
  • Anil Arora,
  • Javier Fernandez,
  • Tawesak Tanwandee,
  • Dong Joon Kim,
  • Mamun-Al-Mahtab,
  • Saeed Hamid,
  • Cosmas Rinaldi A. Lesmana,
  • Gokhan Kabacam,
  • Nipun Verma,
  • Amna Subhan Butt,
  • Daniel Q. Huang,
  • Sunil Taneja,
  • Ashish Goel,
  • Sakkarin Chirapongsathorn,
  • Wasim Jafri,
  • Rakhi Maiwall,
  • R. K. Dhiman,
  • Jasmohan Bajaj,
  • Cesar Yaghi,
  • Barjesh Chander Sharma,
  • Arun Valsan,
  • James Fung,
  • Madhumita Premkumar,
  • Constantine J. Karvellas,
  • Lubna Kamani,
  • Sanjaya K. Satapathy,
  • Igor G. Bakulin,
  • Sumeet Asrani,
  • Hasmik Ghazinian,
  • Akash Roy,
  • Imelda Maria Loho,
  • Diana Alcantara Payawal,
  • Shalimar,
  • Manoj K. Sharma,
  • Ruben Hernaez,
  • Zhongping Duan,
  • Ruveena Bhawani Rajaram,
  • Atsushi Tanaka,
  • Suprabhat Giri,
  • Madunil A. Niriella,
  • Sunil Dadhich,
  • Vinod Arora,
  • Jun Li,
  • Mohd Golam Azam,
  • Rajiv Jalan,
  • Ashish Kumar,
  • Akash Shukla,
  • Santhosh E. Kumar,
  • Vincent Wai-Sun Wong,
  • C. E. Eapen,
  • Shahinul Alam,
  • Ming Lung Yu,
  • Yogesh K. Chawla,
  • Gamal E. Shiha,
  • Ajay Duseja,
  • Soek Siam Tan,
  • Narendra Singh Choudhary,
  • Mohamed Rela,
  • Albert C. Y. Chan,
  • Prashant Bhangui,
  • Francois Durand,
  • Ramon Bataller,
  • Mark Dhinesh Muthiah,
  • Nadim Mahmud,
  • Mamatha Bhat,
  • Sanjiv Saigal,
  • Juan Pablo Arab,
  • Yoon Jun Kim,
  • Manal Hamdy El-Sayed,
  • Jinlin Hou,
  • Jidong Jia,
  • Necati Ormeci,
  • Lai Wei,
  • Masao Omata,
  • Paul Y. Kwo,
  • Shiv Kumar Sarin,
  • Qin Ning

摘要

Background and aims

Acute-on-chronic liver failure (ACLF) is a severe syndrome in patients with chronic liver disease, marked by rapid multi-organ failure and high short-term mortality. Managing ACLF requires intensive care, but standardized global guidelines were previously lacking. The APASL ACLF Research Consortium (AARC) developed this position paper to establish a unified, evidence-based consensus for its critical care management.

Methods

A global collaboration of 109 experts employed a systematic methodology to address key aspects of ACLF care. Sections were drafted by specialist teams, with recommendations developed using the GRADE system. Draft statements underwent iterative review and refinement, followed by an expert panel consensus process consisting of open show-of-hands voting during the APASL Annual Conference in March 2025 in Beijing and a subsequent anonymous online voting round.

Results

The consensus delivers 104 position statements. Key recommendations include using prognostic scores (AARC, CLIF-C ACLF, GIC) for ICU transfer and treatment decisions, and aggressively managing precipitating factors or complications like infections. It details organ-specific support for liver, kidney, and brain failure, advocating for early, targeted antibiotics and careful fluid management. The role of bridging therapies (plasma exchange, artificial liver systems) and nutritional support is emphasized. For transplantation, the guidelines provide criteria for patient selection and timing, particularly for alcohol-related ACLF.

Conclusions

The APASL ACLF Beijing Position Paper provides a comprehensive, standardized framework for managing critically sick ACLF patients. Integrating multidisciplinary expertise and current evidence, these guidelines aim to optimize care, inform clinical decisions, and improve survival for this high-risk population. As a few recommendations are supported predominantly by data from different continents, they should therefore be interpreted in local contexts.