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Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL)

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Abstract

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.

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Notes

  1. No consensus.

References

  1. Centre for evidence-based medicine. Levels of evidence. 2001. http://www.cebm.net/index.aspx?o=1047. Accessed 12 Oct 2008

  2. Ohnishi H, Sugihara J, Moriwaki H, Muto Y. Acute-on-chronic liver failure. Ryoikibetsu Shokogun Shirizu 1995;(7):217–219

  3. O’Grady JG, Schalm SW, Williams R. Acute liver failure: redefining the syndromes. Lancet 1993;342:273–275

    Article  PubMed  CAS  Google Scholar 

  4. Bernuau J, Rueff B, Benhamou JP. Fulminant and subfulminant liver failure: definitions and causes. Semin Liver Dis 1986;6:97–106

    Article  PubMed  CAS  Google Scholar 

  5. Gimson AE, O’Grady J, Ede RJ, Portmann B, Williams R. Late onset hepatic failure: clinical, serological and histological features. Hepatology 1986;6:288–294

    Article  PubMed  CAS  Google Scholar 

  6. Lee WM, Squires RH Jr, Nyberg SL, Doo E, Hoofnagle JH. Acute liver failure: summary of a workshop. Hepatology 2008;47:1401–1415

    Article  PubMed  Google Scholar 

  7. Kohrt HE, Ouyang DL, Keeffe EB. Antiviral prophylaxis for chemotherapy-induced reactivation of chronic hepatitis B virus infection. Clin Liver Dis 2007;11:965–991

    Article  PubMed  Google Scholar 

  8. Millonig G, Kern M, Ludwiczek O, Nachbaur K, Vogel W. Subfulminant hepatitis B after infliximab in Crohn’s disease: need for HBV-screening? World J Gastroenterol 2006;12:974–976

    PubMed  Google Scholar 

  9. Sheng WH, Kao JH, Chen PJ, Huang LM, Chang SY, Sun HY, et al. Evolution of hepatitis B serological markers in HIV-infected patients receiving highly active antiretroviral therapy. Clin Infect Dis 2007;45:1221–1229

    Article  PubMed  Google Scholar 

  10. Paitoonpong L, Suankratay C. Immunological response to hepatitis B vaccination in patients with AIDS and virological response to highly active antiretroviral therapy. Scand J Infect Dis 2008;40:54–58

    Article  PubMed  CAS  Google Scholar 

  11. Flink HJ, Sprengers D, Hansen BE, van Zonneveld M, de Man RA, Schalm SW, et al. Flares in chronic hepatitis B patients induced by the host or the virus? Relation to treatment response during Peg-interferon {alpha}-2b therapy. Gut 2005;54:1604–1609

    Article  PubMed  CAS  Google Scholar 

  12. Perceau G, Diris N, Estines O, Derancourt C, Lévy S, Bernard P. Late lethal hepatitis B virus reactivation after rituximab treatment of low-grade cutaneous B-cell lymphoma. Br J Dermatol 2006;155:1053–1056

    Article  PubMed  CAS  Google Scholar 

  13. Sera T, Hiasa Y, Michitaka K, Konishi I, Matsuura K, Tokumoto Y, et al. Anti-HBs-positive liver failure due to hepatitis B virus reactivation induced by rituximab. Intern Med 2006;45:721–724

    Article  PubMed  Google Scholar 

  14. Locasciulli A, Bruno B, Alessandrino EP, Meloni G, Arcese W, Bandini G, et al. Hepatitis reactivation and liver failure in haemopoietic stem cell transplants for hepatitis B virus (HBV)/hepatitis C virus (HCV) positive recipients: a retrospective study by the Italian group for blood and marrow transplantation. Bone Marrow Transplant 2003;31:295–300

    Article  PubMed  CAS  Google Scholar 

  15. Hsieh CY, Huang HH, Lin CY, Chung LW, Liao YM, Bai LY, et al. Rituximab-induced hepatitis C virus reactivation after spontaneous remission in diffuse large B-cell lymphoma. J Clin Oncol 2008;26:2584–2586

    Article  PubMed  Google Scholar 

  16. Hamid SS, Atiq M, Shehzad F, Yasmeen A, Nissa T, Salam A, et al. Hepatitis E virus superinfection in patients with chronic liver disease. Hepatology 2002;36:474–478

    Article  PubMed  Google Scholar 

  17. Ramachandran J, Eapen CE, Kang G, Abraham P, Hubert DD, Kurian G, et al. Hepatitis E superinfection produces severe decompensation in patients with chronic liver disease. J Gastroenterol Hepatol 2004;19:134–138

    Article  PubMed  Google Scholar 

  18. Monga R, Garg S, Tyagi P, Kumar N. Superimposed acute hepatitis E infection in patients with chronic liver disease. Indian J Gastroenterol 2004;23:50–52

    PubMed  Google Scholar 

  19. Kumar M, Sharma BC, Sarin SK. Hepatitis E virus as an etiology of acute exacerbation of previously unrecognized asymptomatic patients with hepatitis B virus-related chronic liver disease. J Gastroenterol Hepatol 2008;23(6):83–87

    Article  Google Scholar 

  20. Acharya SK, Sharma PK, Singh R, Mohanty SK, Madan K, Jha JK, et al. Hepatitis E virus (HEV) infection in patients with cirrhosis is associated with rapid decompensation and death. J Hepatol 2007;46:387–394

    Article  Google Scholar 

  21. Chung RT, Friedman LS. Bacterial, parasitic, and fungal infections of the liver, including liver abscess. In Feldman M, Friedman LS, Brandt LJ, editors. Sleisenger and Fordtran’s Gastrointestinal and Liver Disease. 8th ed. Philadelphia: WB Saunders; 2006. p. 1731

    Google Scholar 

  22. Laleman W, Wilmer A, Evenepoel P, Elst IV, Zeegers M, Zaman Z, et al. Effect of the molecular adsorbent recirculating system and Prometheus devices on systemic haemodynamics and vasoactive agents in patients with acute-on-chronic alcoholic liver failure. Crit Care 2006;10:R108

    Article  PubMed  Google Scholar 

  23. Sen S, Davies NA, Mookerjee RP, Cheshire LM, Hodges SJ, Williams R, et al. Pathophysiological effects of albumin dialysis in acute-on-chronic liver failure: a randomized controlled study. Liver Transpl 2004;10:1109–1119

    Article  PubMed  Google Scholar 

  24. Hessel FP, Mitzner SR, Rief J, Guellstorff B, Steiner S, Wasem J. Economic evaluation and 1-year survival analysis of MARS in patients with alcoholic liver disease. Liver Int 2003;23(Suppl 3):66–72

    PubMed  Google Scholar 

  25. Lee KH, Lee MK, Sutedja DS, Lim SG. Outcome from molecular adsorbent recycling system (MARS) liver dialysis following drug-induced liver failure. Liver Int 2005;25:973–977

    Article  PubMed  CAS  Google Scholar 

  26. Mattéi A, Rucay P, Samuel D, Feray C, Reynes M, Bismuth H. Liver transplantation for severe acute liver failure after herbal medicine (Teucrium polium) administration. J Hepatol 1995;22:597

    Article  PubMed  Google Scholar 

  27. Ripoll C, Groszmann R, Garcia-Tsao G, Grace N, Burroughs A, Planas R, et al. Hepatic venous pressure gradient predicts clinical decompensation in patients with compensated cirrhosis. Gastroenterology 2007;133:481–488

    Article  PubMed  CAS  Google Scholar 

  28. del Olmo JA, Flor-Lorente B, Flor-Civera B, Rodriguez F, Serra MA, Escudero A, et al. Risk factors for nonhepatic surgery in patients with cirrhosis. World J Surg 2003;27:647–652

    Article  PubMed  Google Scholar 

  29. Rice HE, O’Keefe GE, Helton WS, Johansen K. Morbid prognostic features in patients with chronic liver failure undergoing nonhepatic surgery. Arch Surg 1997;132:880–884

    PubMed  CAS  Google Scholar 

  30. Cholongitas E, Senzolo M, Patch D, Kwong K, Nikolopoulou V, Leandro G, et al. Risk factors, sequential organ failure assessment and model for end-stage liver disease scores for predicting short term mortality in cirrhotic patients admitted to intensive care unit. Aliment Pharmacol Ther 2006;23:883–893

    Article  PubMed  CAS  Google Scholar 

  31. Wehler M, Kokoska J, Reulbach U, Hahn EG, Strauss R. Short-term prognosis in critically ill patients with cirrhosis assessed by prognostic scoring systems. Hepatology 2001;34:255–261

    Article  PubMed  CAS  Google Scholar 

  32. Wasmuth HE, Kunz D, Yagmur E, Timmer-Stranghöner A, Vidacek D, Siewert E, et al. Patients with acute on chronic liver failure display “sepsis-like” immune paralysis. J Hepatol 2005;42:195–201

    Article  PubMed  CAS  Google Scholar 

  33. Mitzner SR, Stange J, Klammt S, Risler T, Erley CM, Bader BD, et al. Improvement of hepatorenal syndrome with extracorporeal albumin dialysis MARS: results of a prospective, randomized, controlled clinical trial. Liver Transpl 2000;6:277–286

    Article  PubMed  CAS  Google Scholar 

  34. Heemann U, Treichel U, Loock J, Philipp T, Gerken G, Malago M, et al. Albumin dialysis in cirrhosis with superimposed acute liver injury: a prospective, controlled study. Hepatology 2002;36:949–958

    PubMed  CAS  Google Scholar 

  35. Zauner C, Schneeweiss B, Schneider B, Madl C, Klos H, Kranz A, et al. Short-term prognosis in critically ill patients with liver cirrhosis: an evaluation of a new scoring system. Eur J Gastroenterol Hepatol 2000;12:517–522

    Article  PubMed  CAS  Google Scholar 

  36. Choi JY, Bae SH, Yoon SK, Cho SH, Yang JM, Han JY, et al. Preconditioning by extracorporeal liver support (MARS) of patients with cirrhosis and severe liver failure evaluated for living donor liver transplantation—a pilot study. Liver Int 2005;25:740–745

    Article  PubMed  CAS  Google Scholar 

  37. Wagholikar GD, Lee KH, Pandey D, Leong SO, Singh R, Tan KC. Pre-transplant optimization by molecular adsorbent recirculating system in patients with severely decompensated chronic liver disease. Indian J Gastroenterol 2007;26:110–112

    PubMed  Google Scholar 

  38. Wai CT, Lim SG, Aung MO, Lee YM, Sutedja DS, Dan YY, et al. MARS: a futile tool in centres without active liver transplant support. Liver Int 2007;27:69–75

    PubMed  CAS  Google Scholar 

  39. Du WB, Li LJ, Huang JR, Yang Q, Liu XL, Li J, et al. Effects of artificial liver support system on patients with acute or chronic liver failure. Transplant Proc 2005;37:4359–4364

    Article  PubMed  CAS  Google Scholar 

  40. Polson J, Lee WM, American Association for the Study of Liver Disease. AASLD position paper: the management of acute liver failure. Hepatology 2005;41:1179–1197

    Article  PubMed  Google Scholar 

  41. Sen S, Williams R, Jalan R. The pathophysiological basis of acute-on-chronic liver failure. Liver 2002;22(Suppl 2):5–13

    PubMed  Google Scholar 

  42. Jalan R, Williams R. Acute-on-chronic liver failure: pathophysiological basis of therapeutic options. Blood Purif 2002;20:252–261

    Article  PubMed  Google Scholar 

  43. Stadlbauer V, Krisper P, Aigner R, Haditsch B, Jung A, Lackner C, et al. Effect of extracorporeal liver support by MARS and Prometheus on serum cytokines in acute-on-chronic liver failure. Crit Care 2006;10:R169

    Article  PubMed  Google Scholar 

  44. Liu Q, Liu Z, Wang T, Wang Q, Shi X, Dao W. Characteristics of acute and sub-acute liver failure in China: nomination, classification and interval. J Gastroenterol Hepatol 2007;22:2101–2106

    Article  PubMed  Google Scholar 

  45. Tilg H, Diehl AM. Cytokines in alcoholic and nonalcoholic steatohepatitis. N Engl J Med 2000;343:1467–1476

    Article  PubMed  CAS  Google Scholar 

  46. Mookerjee RP, Stadlbauer V, Lidder S, Wright GA, Hodges SJ, Davies NA, et al. Neutrophil dysfunction in alcoholic hepatitis superimposed on cirrhosis is reversible and predicts the outcome. Hepatology 2007;46:831–840

    Article  PubMed  CAS  Google Scholar 

  47. Mookerjee RP, Dalton RN, Davies NA, Hodges SJ, Turner C, Williams R, et al. Inflammation is an important determinant of levels of the endogenous nitric oxide synthase inhibitor asymmetric dimethylarginine (ADMA) in acute liver failure. Liver Transpl 2007;13:400–405

    Article  PubMed  Google Scholar 

  48. Lluch P, Mauricio MD, Vila JM, Segarra G, Medina P, Del Olmo JA, et al. Accumulation of symmetric dimethylarginine in hepatorenal syndrome. Exp Biol Med (Maywood) 2006;231:70–75

    CAS  Google Scholar 

  49. Vizzutti F, Romanelli RG, Arena U, Rega L, Brogi M, Calabresi C, et al. ADMA correlates with portal pressure in patients with compensated cirrhosis. Eur J Clin Invest 2007;37:509–515

    Article  PubMed  CAS  Google Scholar 

  50. Lluch P, Torondel B, Medina P, Segarra G, Del Olmo JA, Serra MA, et al. Plasma concentrations of nitric oxide and asymmetric dimethylarginine in human alcoholic cirrhosis. J Hepatol 2004;41:55–59

    Article  PubMed  CAS  Google Scholar 

  51. Mookerjee RP, Malaki M, Davies NA, Hodges SJ, Dalton RN, Turner C, et al. Increasing dimethylarginine levels are associated with adverse clinical outcome in severe alcoholic hepatitis. Hepatology 2007;45:62–71

    Article  PubMed  CAS  Google Scholar 

  52. Ambrosino G, Naso A, Feltracco P, Carraro P, Basso SM, Varotto S, et al. Cytokines and liver failure: modification of TNF-α and IL–6 in patients with acute on chronic liver decompensation treated with molecular adsorbent recycling system (MARS). Acta Biomed 2003;74(Suppl 2):7–9

    PubMed  Google Scholar 

  53. Auth MK, Kim HS, Beste M, Bonzel KE, Baumann U, Ballauff A, et al. Removal of metabolites, cytokines and hepatic growth factors by extracorporeal liver support in children. J Pediatr Gastroenterol Nutr 2005;40:54–59

    Article  PubMed  CAS  Google Scholar 

  54. Rolando N, Wade J, Davalos M, Wendon J, Philpott-Howard J, Williams R. The systemic inflammatory response syndrome in acute liver failure. Hepatology 2000;32:734–739

    Article  PubMed  CAS  Google Scholar 

  55. Marsden PA, Ning Q, Fung LS, Luo X, Chen Y, Mendicino M, et al. The Fgl2/fibroleukin prothrombinase contributes to immunologically mediated thrombosis in experimental and human viral hepatitis. J Clin Invest 2003;112:58–66

    PubMed  CAS  Google Scholar 

  56. Zhu CL, Yan WM, Zhu F, Zhu YF, Xi D, Tian DY, et al. Fibrinogen-like protein 2 fibroleukin expression and its correlation with disease progression in murine hepatitis virus type 3-induced fulminant hepatitis and in patients with severe viral hepatitis B. World J Gastroenterol 2005;11:6936–6940

    PubMed  CAS  Google Scholar 

  57. Bosch J, García-Pagán JC. Complications of cirrhosis. I. Portal hypertension. J Hepatol 2000;32(1 Suppl):141–156

    Article  PubMed  CAS  Google Scholar 

  58. Newby DE, Jalan R, Masumori S, Hayes PC, Boon NA, Webb DJ. Peripheral vascular tone in patients with cirrhosis: role of the renin-angiotensin and sympathetic nervous systems. Cardiovasc Res 1998;38:221–228

    Article  PubMed  CAS  Google Scholar 

  59. Kumar A, Das K, Sharma P, Mehta V, Sharma BC, Sarin SK. Hemodynamic studies in acute-on-chronic liver failure. Dig Dis Sci 2008 Aug 9. [Epub ahead of print]

  60. Catalina MV, Barrio J, Anaya F, Salcedo M, Rincón D, Clemente G, et al. Hepatic and systemic haemodynamic changes after MARS in patients with acute on chronic liver failure. Liver Int 2003;23(Suppl 3):39–43

    PubMed  CAS  Google Scholar 

  61. Rastogi A, Sakhuja P, Gondal R, Garg H, Hissar SS, Sarin SK. Liver biopsy is a good predictor of the outcome in patients with acute on chronic liver failure [abstract]. Hepatology 2008;48(Suppl):446A

    Google Scholar 

  62. Sakhuja P, Rastogi A, Gondal R, Garg H, Sarin SK. Acute on chronic liver failure—analysis of two distinct liver histological patterns [abstract]. J Hepatol 2008;48(Suppl 2):S95

    Article  Google Scholar 

  63. Zauner CA, Apsner RC, Kranz A, Kramer L, Madl C, Schneider B, et al. Outcome prediction for patients with cirrhosis of the liver in a medical ICU: a comparison of the APACHE scores and liver-specific scoring systems. Intensive Care Med 1996;22:559–563

    Article  PubMed  CAS  Google Scholar 

  64. Sarin SK, Kumar A, Garg HK. Clinical profile of acute on chronic liver failure (ACLF) and predictors of mortality: a study of 64 patients [abstract]. Hepatology 2008;48(Suppl):450A

    Google Scholar 

  65. Sakka SG, Reinhart K, Meier-Hellmann A. Prognostic value of the indocyanine green plasma disappearance rate in critically ill patients. Chest 2002;122:1715–1720

    Article  PubMed  Google Scholar 

  66. Thabut D, Massard J, Gangloff A, Carbonell N, Francoz C, Nguyen-Khac E, et al. Model for end-stage liver disease score and systemic inflammatory response are major prognostic factors in patients with cirrhosis and acute functional renal failure. Hepatology 2007;46:1872–1882

    Article  PubMed  Google Scholar 

  67. Antoniades CG, Berry PA, Bruce M, Cross TJ, Portal AJ, Hussain MJ, et al. Actin-free Gc globulin: a rapidly assessed biomarker of organ dysfunction in acute liver failure and cirrhosis. Liver Transpl 2007;13:1254–1261

    Article  PubMed  Google Scholar 

  68. Sharma R, Gaze DC, Pellerin D, Mehta RL, Gregson H, Streather CP, et al. Ischemia-modified albumin predicts mortality in ESRD. Am J Kidney Dis 2006;47:493–502

    Article  PubMed  CAS  Google Scholar 

  69. Collinson PO, Gaze DC, Bainbridge K, Morris F, Morris B, Price A, et al. Utility of admission cardiac troponin and “ischemia modified albumin” measurements for rapid evaluation and rule out of suspected acute myocardial infarction in the emergency department. Emerg Med J 2006;23:256–261

    Article  PubMed  CAS  Google Scholar 

  70. Inoue T, Fuke H, Yamamoto N, Ito K, Yutaka KY, Yamanaka SK. Lamivudine for treatment of spontaneous exacerbation and reactivation after immunosuppressive therapy in patients with hepatitis B virus infection. Hepatogastroenterology 2007;54:889–891

    PubMed  CAS  Google Scholar 

  71. Liao CA, Lee CM, Wu HC, Wang MC, Lu SN, Eng HL. Lamivudine for the treatment of hepatitis B virus reactivation following chemotherapy for non-Hodgkin’s lymphoma. Br J Haematol 2002;116:166–169

    Article  PubMed  CAS  Google Scholar 

  72. Hsu C, Hsiung CA, Su IJ, Hwang WS, Wang MC, Lin SF, et al. A revisit of prophylactic lamivudine for chemotherapy-associated hepatitis B reactivation in non-Hodgkin’s lymphoma: a randomized trial. Hepatology 2008;47:844–853

    Article  PubMed  CAS  Google Scholar 

  73. Ling R, Mutimer D, Ahmed M, Boxall EH, Elias E, Dusheiko GM, et al. Selection of mutations in the hepatitis B virus polymerase during therapy of transplant recipients with lamivudine. Hepatology 1996;24:711–713

    Article  PubMed  CAS  Google Scholar 

  74. Zoulim F, Perrillo R. Hepatitis B: reflections on the current approach to antiviral therapy. J Hepatol 2008;48(Suppl 1):S2–S19

    Article  PubMed  CAS  Google Scholar 

  75. Guo LM, Liu JY, Xu DZ, Li BS, Han H, Wang LH, et al. Application of molecular adsorbents recirculating system to remove NO and cytokines in severe liver failure patients with multiple organ dysfunction syndrome. Liver Int 2003;23(Suppl 3):16–20

    PubMed  CAS  Google Scholar 

  76. Khuroo MS, Khuroo MS, Farahat KL. Molecular adsorbent recirculating system for acute and acute-on-chronic liver failure: a meta-analysis. Liver Transpl 2004;10:1099–1106

    Article  PubMed  Google Scholar 

  77. Li LJ, Yang Q, Huang JR, Xu XW, Chen YM, Fu SZ. Effect of artificial liver support system on patients with severe viral hepatitis: a study of four hundred cases. World J Gastroenterol 2004;10:2984–2988

    PubMed  CAS  Google Scholar 

  78. Wai CT, Da Costa M, Sutedja D, Lee YM, Lee KH, Tan KC, et al. Long-term results of liver transplant in patients with chronic viral hepatitis-related liver disease in Singapore. Singapore Med J 2006;47:588–591

    PubMed  CAS  Google Scholar 

  79. Stärkel P, Horsmans Y, Geubel A, Ciccarelli O, Goubau P, Rahier J, et al. Favorable outcome of orthotopic liver transplantation in a patient with subacute liver failure due to the emergence of a hepatitis B YMDD escape mutant virus. J Hepatol 2001;35:679–681

    Article  PubMed  Google Scholar 

  80. Saab S, Kim M, Wright TL, Han SH, Martin P, Busuttil RW. Successful orthotopic liver transplantation for lamivudine-associated YMDD mutant hepatitis B virus. Gastroenterology 2000;119:1382–1384

    Article  PubMed  CAS  Google Scholar 

  81. Osborn MK, Han SH, Regev A, Bzowej NH, Ishitani MB, Tran TT, et al. Outcomes of patients with hepatitis B who developed antiviral resistance while on the liver transplant waiting list. Clin Gastroenterol Hepatol 2007;5:1454–1461

    Article  PubMed  CAS  Google Scholar 

  82. Liu CL, Fan ST, Lo CM, Wei WI, Yong BH, Lai CL, et al. Live-donor liver transplantation for acute-on-chronic hepatitis B liver failure. Transplantation 2003;76:1174–1179

    Article  PubMed  Google Scholar 

  83. Andreu M, Sola R, Sitges-Serra A, Alia C, Gallen M, Vila MC, et al. Risk factors for spontaneous bacterial peritonitis in cirrhotic patients with ascites. Gastroenterology 1993;104:1133–1138

    PubMed  CAS  Google Scholar 

  84. Ginès A, Escorsell A, Ginès P, Saló J, Jiménez W, Inglada L, et al. Incidence, predictive factors, and prognosis of the hepatorenal syndrome in cirrhosis with ascites. Gastroenterology 1993;105:229–236

    PubMed  Google Scholar 

  85. Rolando N, Harvey F, Brahm J, Philpott-Howard J, Alexander G, Gimson A, et al. Prospective study of bacterial infection in acute liver failure: an analysis of fifty patients. Hepatology 1990;11:49–53

    Article  PubMed  CAS  Google Scholar 

  86. Rolando N, Harvey F, Brahm J, Philpott-Howard J, Alexander G, Casewell M, et al. Fungal infection: a common, unrecognised complication of acute liver failure. J Hepatol 1991;12:1–9

    Article  PubMed  CAS  Google Scholar 

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Authors and Affiliations

  1. Department of Gastroenterology, G. B. Pant Hospital, Affiliated to University of Delhi, Jawahar Lal Nehru Road, New Delhi, 110 002, India

    Shiv Kumar Sarin, Hitendra Garg, Barjesh Chander Sharma & Praveen Sharma

  2. Department of Hepatology, Institute of Liver & Biliary Sciences (ILBS), D-1 Vasant Kunj, New Delhi, 110 070, India

    Ashish Kumar & Kaushal Madan

  3. Gastrointestinal and Liver Unit, The Prince of Wales Hospital and University of New South Wales, Barker Street, Randwick 2031, New South Wales, Australia

    John A. Almeida & Stephen M. Riordan

  4. Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

    Yogesh Kumar Chawla

  5. Department of Surgery, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China

    Sheung Tat Fan

  6. Department of Medicine, Faculty of Medicine, University of Kelaniya, P.O. Box 6, Thalagolla Road, Ragama, Sri Lanka

    H. Janaka de Silva

  7. Section of Gastroenterology, Department of Medicine, The Aga Khan University Hospital, Stadium Road, P.O. Box 3500, Karachi , 74800, Pakistan

    Saeed Sadiq Hamid

  8. The University College London (UCL) Institute of Hepatology, Division of Medicine, University College London, 69-75 Chenies Mews, London, WC1E 6HX, UK

    Rajiv Jalan

  9. Department of Medicine, Faculty and Medicine, Chulalongkorn University, Bangkok , 10330, Thailand

    Piyawat Komolmit

  10. Department of Medicine, The University of Hong Kong, Queen Mary Hospital, 102 Pokfulam Road, Hong Kong SAR, China

    George K. Lau & Man-Fung Yuen

  11. Beijing Youan Hospital, Capital University of Medical Sciences, Beijing, China

    Qing Liu

  12. Department of Medicine, Faculty of Medicine, University of Malaya, Kuala Lumpur, 50603, Malaysia

    Rosmawati Mohamed

  13. Laboratory of Infectious Immunology, Department of Infectious Disease, Institute of Immunology, Huazhong University of Science and Technology, Wuhan, China

    Qin Ning

  14. Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh

    Salimur Rahman

  15. Department of Pathology, Institute of Liver & Biliary Sciences (ILBS), D-1 Vasant Kunj, New Delhi, 110 070, India

    Archana Rastogi

  16. Department of Pathology, G. B. Pant Hospital, Affiliated to University of Delhi, Jawahar Lal Nehru Road, New Delhi, 110 002, India

    Puja Sakhuja

  17. INSERM Unité 785, AP-HP Hôpital Paul Brousse, Villejuif, 94800, France

    Didier Samuel

  18. Department of Gastroenterology, Jaslok Hospital and Research Center, 15 - Dr. Deshmukh Marg, Pedder Road, Mumbai, 400 026, India

    Samir Shah

  19. Department of Gastroenterology and Hepatology, Iwate Medical University, 19-1 Uchimaru, Morioka, 020-8505, Japan

    Yasuhiro Takikawa

  20. Division of Pediatric Gastroenterology, Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India

    Babu Ram Thapa

  21. Asian Center for Liver Diseases and Transplantation, Gleneagles Hospital, Annexe Block #02-37, 6A Gleneagles Hospital, Singapore, 258500, Singapore

    Chun-Tao Wai

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  1. Shiv Kumar Sarin
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  2. Ashish Kumar
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Correspondence to Shiv Kumar Sarin.

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Sarin, S.K., Kumar, A., Almeida, J.A. et al. Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific Association for the study of the liver (APASL). Hepatol Int 3, 269–282 (2009). https://doi.org/10.1007/s12072-008-9106-x

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  • DOI: https://doi.org/10.1007/s12072-008-9106-x

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