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 the Asia-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 were circulated to all the experts and 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.

The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. With international groups volunteering to join, the “APASL ACLF Research Consortium (AARC)” was formed in 2012, which continued to collect prospective ACLF patient data. Based on the prospective data analysis of nearly 1400 patients, the AARC consensus was published in 2014. In the past nearly four-and-a-half years, the AARC database has been enriched to about 5200 cases by major hepatology centers across Asia. The data published during the interim period were carefully analyzed and areas of contention and new developments in the field of ACLF were prioritized in a systematic manner. The AARC database was also approached for answering some of the issues where published data were limited, such as liver failure grading, its impact on the ‘Golden Therapeutic Window’, extrahepatic organ dysfunction and failure, development of sepsis, distinctive features of acute decompensation from ACLF and pediatric ACLF and the issues were analyzed. These initiatives concluded in a two-day meeting in October 2018 at New Delhi with finalization of the new AARC consensus. Only those statements, which were based on evidence using the Grade System and were unanimously recommended, were accepted. Finalized statements were again circulated to all the experts and subsequently presented at the AARC investigators meeting at the AASLD in November 2018. The suggestions from the experts were used to revise and finalize the consensus. After detailed deliberations and data analysis, the original definition of ACLF was found to withstand the test of time and be able to identify a homogenous group of patients presenting with liver failure. New management options including the algorithms for the management of coagulation disorders, renal replacement therapy, sepsis, variceal bleed, antivirals and criteria for liver transplantation for ACLF patients were proposed. The final consensus statements along with the relevant background information and areas requiring future studies are presented here.

The first consensus report of the working party of the Asian Pacific Association for the Study of the Liver (APASL) set up in 2004 on acute-on-chronic liver failure (ACLF) was published in 2009. Due to the rapid advancements in the knowledge and available information, a consortium of members from countries across Asia Pacific, ''APASL ACLF Research Consortium (AARC),'' was formed in 2012. A large cohort of retrospective and prospective data of ACLF patients was collated and followed up in this data base. The current ACLF definition was reassessed based on the new AARC data base. These initiatives were concluded on a 2-day meeting in February 2014 at New Delhi and led to the development of the final AARC consensus. Only those statements which were based on the evidence and were unanimously recommended were accepted. These statements were circulated again to all the experts and subsequently presented at the annual conference of the APASL at Brisbane, on March 14, 2014. The suggestions from the delegates were analyzed by the expert panel, and the modifications in the consensus were made. The final consensus and guidelines document was prepared. After detailed deliberations and data analysis, the

Background Animal models of kidney disease have linked metabolic acidosis with renal damage. The role of low serum bicarbonate levels in kidney disease progression in humans has not been studied. Study Design Retrospective cohort study. Setting & Participants: Adults visiting a medical clinic in the Bronx, NY from 01/01/01 to 12/31/03 were included in the study (n=5,422) and followed until 6/30/07 Predictor Serum bicarbonate levels Outcomes Kidney disease progression was defined as either a decline in the estimated glomerular filtration rate (eGFR) by 50% or reaching an eGFR of <15 ml/min/1.73m2 (n=337). Measurements Patients’ baseline demographics, comorbidities, laboratory data and socioeconomic status were recorded. Serial outpatient serum creatinines were collected (median, 5 measurements/ person). Results The mean age was 52 years, 69% were women, 45% were African-American, 31% were Hispanic, 21% had diabetes mellitus, 41% had hypertension, and 9% had a baseline eGFR <60 ml/min/1.73m2. Kidney disease progressed by the definition above in 337 patients (6.2%). Compared to the reference group (bicarbonate level 25-26 mEq/L), the hazard ratio for progression after adjustment for potential confounders was 1.54 (95% CI 1.13-2.09) for bicarbonate levels ≤22 mEq/L, 0.97 (95% CI 0.70-1.35) for levels 23-24 mEq/L and 1.14 (95% CI 0.84-1.55) for levels ≥27 mEq/L. (Global p-value for inclusion of serum bicarbonate in the model, 0.01). These results remained similar when using different definitions of the outcome (an eGFR decline by 30%, 1288 outcomes (24%)) or doubling of serum creatinine (268 outcomes (4.9%)). Limitations Data used in study was collected for clinical, not research, purposes. Conclusions Low serum bicarbonate is associated with the progression of kidney disease, independent of baseline eGFR and other clinical, demographic and socioeconomic factors. Prospective studies are needed to confirm this relationship and to evaluate the efficacy of alkali supplements for slowing progression.