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Limited data exist regarding outcomes of acute variceal bleeding (AVB) in patients with acute-on-chronic liver failure (ACLF), especially in those with hepatic failure. We evaluated the outcomes of AVB in patients with ACLF in a multinational cohort of APASL ACLF Research Consortium (AARC).Prospectively maintained data from AARC database on patients with ACLF who developed AVB (ACLF-AVB) was analysed. This data included demographic profile, severity of liver disease, and rebleeding and mortality in 6 weeks. These outcomes were compared with a propensity score matched (PSM) cohort of ACLF matched for severity of liver disease (MELD, AARC score) without AVB (ACLF without AVB).Of the 4434 ACLF patients, the outcomes in ACLF-AVB (n = 72) [mean age-46 ± 10.4 years, 93% males, 66% with alcoholic liver disease, 65% with alcoholic hepatitis, AARC score: 10.1 ± 2.2, MELD score: 34 (IQR: 27-40)] were compared with a PSM cohort selected in a ratio of 1:2 (n = 143) [mean age-44.9 ± 12.5 years, 82.5% males, 48% alcoholic liver disease, 55.7% alcoholic hepatitis, AARC score: 9.4 ± 1.5, MELD score: 32 (IQR: 24-40)] of ACLF-without AVB. Despite PSM, ACLF patients with AVB had a higher baseline HVPG than without AVB (25.00 [IQR: 23.00-28.00] vs. 17.00 [15.00-21.75] mmHg; p = 0.045). The 6-week mortality in ACLF patients with or without AVB was 70.8% and 53.8%, respectively (p = 0.025). The 6-week rebleeding rate was 23% in ACLF-AVB. Presence of ascites [hazard ratio (HR) 2.2 (95% CI 1.03-9.8), p = 0.026], AVB [HR 1.9 (95% CI 1.2-2.5, p = 0.03)], and MELD score [HR 1.7 (95% CI 1.1-2.1), p = 0.001] independently predicted mortality in the overall ACLF cohort.Development of AVB confers poor outcomes in patients with ACLF with a high 6-week mortality. Elevated HVPG at baseline represents a potential risk factor for future AVB in ACLF.

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., Article Highlights Updated on the basis of AARC data of >3300 cases enrolled into AARC registry prospectivelyACLF is distinct form Acute Decompensation of cirrhosisNewer sections on DILI-ACLF, AIH-ACLF, PVT/HVOTO–ACLFReversibility of Chronic Liver Disease in ACLFPortal and systemic hemodynamics and their relevance in ACLFAcute Portal Hypertension and Variceal progression in ACLFAARC score as a guide for treatment strategies in ACLFACLF in Children-first consensus on pediatric ACLF

S 21 ANNUAL CONFERENCE—2013 Lver ra n sp la n ta tio n including the extremes (mean trough level 8.4 4.4 ng/ dL). At 6 months, 5 recipients were on treatment for NODM. Three recipients developed ACR: 2 within the first month and one at 7 weeks; the trough levels were 8.5 ng/ mL, 9 ng / mL, 15.2 ng/mL respectively. All recovered with three pulse doses of methylprednisolone. Conclusions: Tacrolimus concentration of 5 to 10 kg on mean follow up of 30 months. Conclusion: Pediatric LDLT is well established in India with results comparable to the best centers in world.

S 21 ANNUAL CONFERENCE—2013 N o n -a co h o lic Fa ty Lver D iea se liver and severity of steatosis, inflammation and fibrosis (0.01-0.001). In conclusion, our results show decreased serum levels of hepcidin in patients with nonalcoholic and alcoholic fatty liver diseases, and chronic hepatitis C. The relationships between the parameters of iron metabolism and the severity of liver disease prove the importance of serum hepcidin as a surrogate marker for evaluation of iron overload in patients with chronic liver diseases. 40.74 ng/ ml) compared to the controls (99.14 Abstract Content: Chronic liver diseases, especially alcoholic fatty liver disease (AFLD), nonalcoholic fatty liver disease (NAFLD) and chronic hepatitis C (CHC), are frequently associated with iron overload. Hepcidin is the iron-regulatory hormone, which is synthesized mainly in the liver and plays an important role in iron homeostasis. The aim of this study was to assess the serum levels of hepcidin and to evaluate its relationships with other parameters of iron metabolism in patients with various chronic liver diseases. Material and methods: A total of 186 patients with chronic liver disease (CLD), divided into six groups were studied (115male, 71 – female; mean age 50.41 12.85 y), and 60 healthy controls were studied. Laboratory parameters of liver function and indices of iron metabolism were evaluated. The presence of iron deposition and the histological grades of steatosis and inflammation, and stage of fibrosis were also evaluated in patients with CLD. The serum level of hepcidin was determined by ELISA test / DRG International Inc. (USA). Results: Hepcidin was significantly lower in the whole group of patients with CLD (82.9). Corresponding Author. Mariana Penkova. E-mail: mpenkovadoc@abv.bg HEPATIC STEATOSIS: CORRELATION OF BODY MASS INDEX AND CT FAT MEASUREMENT (LIVER ATTENUATION INDEX) Joy Varghese, R. L. Sunjay, Thomas Cherian, Srinivasa Mettu Reddy, Sunjay Vijaya, Venkataraman Jayanthi, Mohd Rela Department of Hepatology & Liver Transplantation, Global Hospitals & Health City, Chennai, India Introduction: Several studies have evaluated non-invasive methods of predicting the presence of fatty liver disease which utilizes complex imaging measures such as intra-abdominal mesenteric fat cross-sectional area measurements, magnetic resonance (MR) elastography, and MR spectroscopy.Most of themmay limit quick and practical clinical applications.Liver attenuation index (LAI) has beenwidelyused to predict steatosis in donor liver. More recently metabolic syndrome has also been used to predict hepatic steatosis. S30 Objective: To examine the relationship of bodymass index (BMI) with liver attenuation index (LAI), in predicting hepatic steatosis in donor liver. Methodology: All donors registered in the Liver Transplant Clinic had a detailed work up for fitness for donation. A retrospective study was done to compare the BMI of liver donors with the Liver Attenuation Index (LAI) noted at Contrast Enhanced Computed Tomography. The latter was considered as the gold standard for assessment of hepatic steatosis in this study. Liver Attenuation Index (LAI), was derived and defined as the difference between mean hepatic and mean splenic attenuation. The BMI standardized for south Asians (Western Pacific Region of WHO criteria pertaining to obesity (WPRO criteria, 2000) was used to categorise our patients. Normal BMI 18.5 to 22.9 kg/m2, underweight + 5, 0 to 5 as mild steatosis and less than 0 as severe steatosis. Only patients who had details of both BMI and LAI were included for the analysis.The Ethics Committee of the Institution approved the study. Statistical Analysis: The prediction value was determined using positive predictive value (PPV) and negative predictive value (NPV). Results: One hundred and forty donors were screened between Nov 2009 and April 2012 for 76 liver transplant recipients. There were 67 (47.8%) females. The median age of donors was 31 yrs (range 18 to 52 years). 101 donors had information on both BMI and LAI. There were 69 donors whose BMI was more than > 23; 21 of these donors had steatosis on LAI (PPV 30.4%). For 32 donors with BMI < 23 kg/m, only 2 (6.8%) had steatosis on LAI i.e. LAI was normal in 30 donors (NPV 93.8%). Conclusion: A normal BMI (18.5 to 22.9 kg/m 2) is a good predictor of steatosis and can be used as an initial screening parameter for screening patients for hepatic steatosis. However, this cannot be taken as the only parameter for predicting hepatic steatosis especially for donors with normal BMI. The study needs to be validated among larger number of donors. Corresponding Author. Joy Varghese. E-mail: joyvargese@gmail.com COMPARISON OF HISTOPATHOLOGICAL PROFILE BETWEEN YOUNG AND OLDER NAFLD PATIENTS Girish Kumar Pati, Shivaram Prasad Singh, Ayaskant Singh, BijayMisra, DebasisMisra, Pallavi Bhuyan, Niranjan Rout, Sanjib Kumar Kar, Manas Kumar Panigrahi, Chudamani Meher, Omprakash Agrawal