A NEW multicentre study has shed light on the divergent clinical features and outcomes of acute-on-chronic liver failure (ACLF), comparing hepatitis B virus (HBV)-related and alcohol-related cases across varying disease severities. ACLF is a life-threatening condition marked by rapid deterioration and high short-term mortality, yet global disagreement on diagnostic criteria has hindered timely intervention.
The study highlights stark contrasts in ACLF triggers across regions: HBV predominates in Eastern countries such as China, while alcohol is the main culprit in the West. Using the World Gastroenterology Organization (WGO) classification, which categorises ACLF by the severity of pre-existing liver disease (types A, B, and C), researchers found that these two etiologies follow distinct clinical trajectories.
HBV-related ACLF is typically triggered by viral reactivation, presenting with severe liver dysfunction and elevated liver enzymes. In contrast, alcohol-related ACLF is more often precipitated by bacterial infection, driven by systemic inflammation and immune dysregulation. These patients were more likely to experience extrahepatic organ failures, including kidney, brain, and respiratory complications.
Importantly, the study found that while HBV and alcohol-related ACLF differ in presentation, overall mortality outcomes were similar. Instead, survival was strongly linked to the burden of organ failure, particularly among type C ACLF patients, those with previously decompensated cirrhosis, who exhibited over 45% 90-day mortality. Predictive models incorporating extrahepatic dysfunction, such as the CLIF-C ACLF and COSSH-ACLF II scores, outperformed traditional liver-focused metrics like MELD in identifying high-risk patients.
These findings stress the need for tailored clinical management. HBV-related ACLF requires rapid antiviral therapy, while alcohol-related cases benefit from robust infection control and multi-organ support. Despite study limitations such as its retrospective design and exclusion of emerging liver disease causes, this research represents a significant step toward precision treatment and globally harmonised care for ACLF patients.
Reference
Zhang Q et al. Clinical differences between HBV and alcohol related ACLF in a WGO classification multicenter study. Sci Rep. 2025;15(1):25292.
