Correction to: Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update

The article Acute-on-chronic liver failure: consensus recommendations of the Asian Pacific association for the study of the liver (APASL): an update, written by [Shiv Sarin], was originally published electronically on the publisher's internet portal (currently SpringerLink) on June 06, 2019 without open access.

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

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.

Auxiliary liver transplantation: a form of gene therapy in selective metabolic disorders

Auxiliary liver transplantation is an accepted form of therapy in acute liver failure and in certain metabolic disorders. We report India's first successful auxiliary liver transplantation for Crigler-Najjar syndrome type 1, showing that it is technically feasible and safe procedure. It is utmost important to select appropriate cases for auxiliary transplant for successful long-term outcome. The surgeon should also have an understanding of the portal flow dynamics, as steal phenomenon can occur, depriving blood blow to either graft or native liver. Though successful in animal models, gene therapy is still in experimental stage in humans and pace of progress has been disappointing. Auxiliary liver transplantation retains the native liver for future gene therapy. These children are young and are likely to have a long life expectancy, and withdrawal of immunosuppression would be a huge advantage.

Are patients' sedation preferences at gastroscopy influenced by preceding patients' decisions?

BACKGROUND

When patients choose sedation or no sedation for gastroscopy, it is unknown whether the decision and experience of preceding patients on the same endoscopy list influence such decisions.

AIM

To address this question in an endoscopy unit, where pre- and postprocedure patients are free to communicate.

METHODS

The order and sedation decisions of 503 out-patients attending diagnostic gastroscopy lists were analysed. One hundred patients completed a preprocedural questionnaire about sedation preferences.

RESULTS

Three hundred and fifteen (63%) patients chose no sedation. Men were more likely to be unsedated, 170 (72%), than women 158 (59%) (chi(2) = 9.1, P < 0.01). Age did not influence decisions. If the first patient on an endoscopy list requested sedation, 36% of subsequent patients were also sedated. This was similar to 38% of subsequently sedated patients on lists where the first patient was unsedated. Similar proportions of subsequent patients requested sedation when comparing lists where the first two patients were both sedated or both unsedated and when comparing lists where the first three patients were all sedated or all unsedated. Ninety per cent of the patients completing preprocedural questionnaires had made sedation choices before arrival; the remaining undecided patients had unsedated endoscopies.

CONCLUSIONS

Patients' sedation decisions are not influenced by preceding patients' decisions. Most patients attending for out-patient gastroscopy have already decided about sedation.