Abstract
BACKGROUND AND AIM: Acute-on-chronic liver failure (ACLF) carries high short-term mortality, but real-world evidence under the Japanese ACLF criteria remains limited. We assessed incidence, clinical profile, outcomes, and prognostic factors at a tertiary center in urban Japan. METHODS: We retrospectively reviewed 363 consecutive hospitalizations of patients with cirrhosis (2014-2022) at a tertiary care center in Japan. ACLF per Japanese criteria was categorized as confirmed (meeting both PT INR/PT activity and bilirubin thresholds) or extended (meeting either biochemical criterion alone). We pre-specified a parsimonious Cox model with age (per 10 years) and MELD-Na (per 5 points); the primary outcome was time to all-cause death within 90 days (administrative censoring at day 90). RESULTS: ACLF occurred in 40/363 (11.0%) patients (confirmed n = 10, extended n = 30). Frequent precipitants were infection, gastrointestinal bleeding, and alcohol use, often in combination. The 90-day mortality by Kaplan-Meier was 30.5%. Age (per 10 years) was associated with higher 90-day mortality (HR, 2.29; 95% CI 1.31-4.00; p < 0.01), as was Model for End-Stage Liver Disease including sodium (MELD-Na) (per 5 points) (HR, 1.74; 95% CI 1.16-2.63; p < 0.01). CONCLUSIONS: In this Japanese single center cohort, ACLF (per national criteria) was not rare and carried substantial short-term mortality. Age and MELD-Na were dominant prognostic factors, underscoring early trigger control (notably infection, gastrointestinal bleeding, and alcohol cessation) and timely risk stratification in routine care.