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 conventional incision for donor hepatectomy is a right subcostal incision with a midline extension. With increased experience in both donor hepatectomy and laparoscopy, the conventional incision can be shortened to a significant extent. Laparoscopic mobilization of the liver coupled with a hand port allows the insertion of one hand inside the abdomen for control; this makes small-incision donor hepatectomy a technically feasible alternative. We compared 26 right lobe donor hepatectomies performed with a laparoscopy-assisted technique (the laparoscopy-assisted donor hepatectomy group) to 24 donor hepatectomies performed with the conventional open technique (the conventional donor hepatectomy group). The donors in both groups and their recipients were followed for 6 months. Pain, discomfort related to the scar [including abdominal wall sensorineural deficits (numbness and differences in tactile and temperature sensations) and tightness around the scar], and donor quality of life (assessed with the International Quality of Life Assessment Short Form 8 scoring system) were compared between the 2 groups. In conclusion, laparoscopy-assisted surgery can be a technically feasible alternative in experienced hands, and as with other minimally invasive surgeries, it has advantages such as significantly less pain, reduced incision-related complications, and better donor quality of life during the early postoperative period without compromising donor safety.

Biliary complications are regarded as the Achilles' heel of liver transplantation, especially for living donor liver transplantation (LDLT) due to smaller, multiple ducts and difficult ductal anatomy. Overall biliary complications reported in most series are between 10% and 30%. This study describes our modified technique of biliary anastomosis and its effects on incidence of biliary complications. This was a single‐center retrospective study of 148 adult LDLT recipients between December 2011 and June 2014. Group 1 (n = 40) consisted of the first 40 patients for whom the standard technique of biliary anastomosis (minimal hilar dissection during donor duct division, high hilar division of the recipient bile duct, and preservation of the recipient duct periductal tissue) was used. Group 2 (n = 108) consisted of 108 patients for whom biliary anastomosis was done with the addition of corner‐sparing sutures and mucosal eversion of the recipient duct to the standard technique. Primary outcome measures included biliary complications (biliary leaks and strictures). Biliary complications occurred in 7/40 patients in group 1 (17.5%) and in 4/108 patients in group 2 (3.7%). The technical factors mentioned above are aimed at preserving the blood supply of the donor and recipient ducts and hold the key for minimizing biliary complications in adult‐to‐adult LDLT. Liver Transpl 22:14‐23, 2016. © 2015 AASLD.

Background Transfusion management during liver transplantation (LT) is aimed at reducing blood loss and allogeneic transfusion requirements. Although prothrombin complex concentrate (PCC) has been used satisfactorily in various bleeding disorders, studies on its safety, and efficacy during LT are limited. Methods A retrospective chart review of adult patients who underwent living donor LT at a single institute between October 2016 and January 2018 was carried out. The safety and efficacy of PCC in reducing transfusion requirements intraoperatively in patients who received PCC were compared with patients who did not receive PCC. A propensity score‐matching technique was used, at a 1:1 ratio, to remove selection bias. Results After completing the 1:1 propensity score‐matched analysis, 60 pairs of patients were identified. The use of PCC was associated with significantly decreased red blood cell transfusion requirements (6.2 ± 4.1 vs 8.23 ± 5.18, P < 0.001) and fresh frozen plasma transfusion requirements (2.6 ± 2 vs 6.18 ± 4.1, P < 0.001). The number of patients developing postoperative hemorrhagic complications was higher in the non‐PCC group. Conclusions During LT, the use of PCC led to decreased transfusion requirements. No thromboembolic complications related to PCC were noted in this series.

Congenital portosystemic shunts are the anomalies in which the mesenteric venous drainage bypasses the liver and drains directly into the systemic circulation. This is a report of a rare case of LDLT in a four-yr old male child suffering with biliary atresia (post-failed Kasai procedure) associated with (i) a large congenital CEPSh from the spleno-mesentric confluence to the LHV, (ii) intrapulmonary shunts, (iii) perimembranous VSD. The left lobe graft was procured from the mother of the child. Recipient IVC and the shunt vessel were preserved during the hepatectomy, and the caval and shunt clamping were remarkably short while performing the HV and portal anastomosis. Post-operative course was uneventful; intrapulmonary shunts regressed within three months after transplantation and currently after 18 months following transplant child is doing well with normal liver functions. CEPSh has been extensively discussed and all the published cases of liver transplantation for CEPSh were reviewed.

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.

Many infections are transmitted from a donor to a recipient through organ transplantations. The transmission of dengue virus from a donor to a recipient in liver transplantation is a rare entity, and currently, there is no recommendation for screening this virus prior to transplantation. We report a case of transmission of dengue virus from donor to recipient after liver transplantation. The recipient had a history of multiple admissions for hepatic encephalopathy and ascites. He was admitted in the ICU for 15 days for chronic liver disease, ascites, and acute kidney injury before transplantation. The donor was admitted 1 day before transplantation. The donor spiked fever on postoperative day 2 followed by thrombocytopenia and elevated liver enzymes. The donor blood test was positive for dengue NS1 antigen. The recipient also had a similar clinical picture on postoperative day 5 and his blood test was also positive for dengue NS1 antigen. Hence, the diagnosis for posttransplant donorderived allograft-related transmission of dengue infection was made. Both recipient and donor were treated with supportive measures and discharged after their full recovery on postoperative days 9 and 18, respectively. The effect of immunosuppression on dengue presentation is still unclear and there is lack of literature available. In our case, the recipient developed dengue fever similar to general population without showing any feature of severe graft dysfunction. We have concluded that dengue virus can also be transmitted from donor to recipient, and immunosuppression did not have any adverse effect on the evolution of dengue fever within the recipient. Delhi being a hyperendemic zone, screening for donors (especially in season time) for dengue virus seems to be the best preventive method to control donor-derived transmission of dengue to recipient. ( J CLIN EXP HEPATOL 2016;6:59-61) T he epidemiology of dengue, an endemic disease, has been changing rapidly in Delhi. Transmission of dengue virus from donor to recipient is rarely reported. Currently, there is no recommendation for screening this virus prior to transplantation. We describe a case of transmission of dengue virus from donor to recipient after liver transplantation. CASEA 40-year-old man presented with cryptogenic liver disease (since 2013). He was admitted with features suggestive of decompensated chronic liver disease with ascites (no SBP), AKI, and hepatic encephalopathy. He had history of multiple admissions in the past with a diagnosis of hepatic encephalopathy. In view of recurrent hepatic encephalopathy and decompensated chronic liver disease with child class C (13/15) MELD score of 26, the patient was advised for liver transplantation. The donor was his 29-year-old brother-in-law, who was admitted 1 day prior to transplant. He was evaluated as per protocol. After stabilization of recipient (15th day of his admission), he underwent living donor liver transplantation, which was uneventful.The donor spiked fever of 103 8F on POD 3 and continued to have fever for t...

Echinococcus multilocularis (EM) is the most virulent species of the genus Echinococcus. It causes a highly lethal helminthic disease in humans. The disease may present as hepatic mass mimicking a malignant neoplasm. Due to the vascular and neural invasion, protean clinical manifestations including Budd-Chiari syndrome (BCS) may be the clinical presentation of this condition. We herein report three cases of Echinococcus multilocularis; the first case presenting as multiple hepatic space-occupying lesions, second as liver mass infiltrating the nerve bundles, and the third as a hepatic mass infiltrating the large vessels including inferior vena cava and right hepatic vein presenting as BCS. EM is a parasite with capabilities of mass-forming effect, neural and vascular invasion. Though cases of BCS have been described, most of these are due to secondary compression and rarely by direct parasitic invasion.