This APASL consensus position paper, developed by 109 global experts using the GRADE system, establishes standardized critical care management recommendations for acute-on-chronic liver failure (ACLF). It covers ICU triage, organ-specific support (liver, kidney, brain, cardiac), infection management, bridging therapies (plasma exchange, artificial liver support), nutrition, and liver transplantation selection and timing.
The paper delivers 104 position statements. Key actionable outputs include: use of AARC, CLIF-C ACLF, and GIC scores for ICU transfer decisions (strong, high LoE); terlipressin + albumin as first-line for HRS-AKI (strong, high LoE); CRRT preferred over intermittent RRT in hemodynamically unstable ACLF (weak, low LoE); MAP target 65–75 mmHg with lactate <2 mmol/L in shock (strong, high LoE); viscoelastic tests (TEG/ROTEM) over conventional INR to guide transfusion (strong, moderate LoE); plasma exchange as a bridge to transplant in selected patients without infection, shock, or ventilation (moderate LoE); and transplantation ideally within 30 days of listing (strong, moderate LoE).
- Several recommendations rest on regional (Asia-Pacific or European) data and may not generalize globally. - Some statements carry strong recommendations despite low-certainty evidence, with justifications provided only in supplementary material. - No patient or public involvement in consensus development.
Use serial prognostic scoring (AARC, CLIF-C ACLF) at days 0, 3, 7, and 14 to guide ICU-level care and transplant listing; prioritize early terlipressin + albumin for HRS-AKI, viscoelastic testing over INR for bleeding decisions, and targeted antibiotic de-escalation at 24–48 hours when cultures are negative. For alcohol-related ACLF Grade III, withhold transplant listing if active infection, inability to achieve pre-transplant abstinence, or absent psychosocial support are present.
