APASL clinical practice guidelines on the management of acute kidney injury in acute-on-chronic liver failure

Rakhi Maiwall, Satender Pal Singh, Paolo Angeli, Richard Moreau, Aleksander Krag, Virender Singh, Ashwani K. Singal, S. S. Tan, Puneet Puri, Mamun Mahtab, George Lau, Qin Ning, Manoj Kumar Sharma, P. N. Rao, Dharmesh Kapoor, Subhash Gupta, Ajay Duseja, Manav Wadhawan, Dinesh Jothimani, Sanjiv SaigalSunil Taneja, Akash Shukla, Pankaj Puri, Deepak Govil, Gaurav Pandey, Kaushal Madan, C. E. Eapen, Jaya Benjamin, Ashok Chowdhury, Shweta Singh, Vaishali Salao, Jin Mo Yang, Saeed Hamid, Shalimar, Sanjiv Jasuja, Anand V. Kulkarni, Madund A. Niriella, Harsh Vardhan Tevethia, Vinod Arora, R. P. Mathur, Akash Roy, Ankur Jindal, Neeraj Saraf, Nipun Verma, Arka De, Narendra S. Choudhary, Rohit Mehtani, Phool Chand, Omkar Rudra, Shiv Kumar Sarin

Research output: Contribution to journalArticlepeer-review


Acute-on-chronic liver failure (ACLF) is a syndrome that is characterized by the rapid development of organ failures predisposing these patients to a high risk of short-term early death. The main causes of organ failure in these patients are bacterial infections and systemic inflammation, both of which can be severe. For the majority of these patients, a prompt liver transplant is still the only effective course of treatment. Kidneys are one of the most frequent extrahepatic organs that are affected in patients with ACLF, since acute kidney injury (AKI) is reported in 22.8–34% of patients with ACLF. Approach and management of kidney injury could improve overall outcomes in these patients. Importantly, patients with ACLF more frequently have stage 3 AKI with a low rate of response to the current treatment modalities. The objective of the present position paper is to critically review and analyze the published data on AKI in ACLF, evolve a consensus, and provide recommendations for early diagnosis, pathophysiology, prevention, and management of AKI in patients with ACLF. In the absence of direct evidence, we propose expert opinions for guidance in managing AKI in this very challenging group of patients and focus on areas of future research. This consensus will be of major importance to all hepatologists, liver transplant surgeons, and intensivists across the globe.

Original languageEnglish
JournalHepatology International
Publication statusAccepted/In press - 2024


  • ACLF
  • AKI
  • Portal hypertension


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