中文｜English
ISSN 1001-5256 (Print)
ISSN 2097-3497 (Online)
CN 22-1108/R
Volume 42 Issue 8
Aug.  2026
Turn off MathJax
Article Contents
Article Navigation >  Journal of Clinical Hepatology  > 2026  >  42(8): 1749-1754

Research advances in acute-on-chronic liver failure with infection

DOI: 10.12449/JCH260802

  • Department of Gastroenterology and Hepatology，The First Affiliated Hospital of Nankai University/Tianjin People’s Hospital，Tianjin 300121，China

Research funding:

National Natural Science Foundation of China (82470660);

National Natural Science Foundation of China (82170630)

More Information
  • Corresponding author: Han Tao， hantaomd@126.com （ORCID： 0000-0003-4216-6968）
  • Received Date: 2026-05-06
  • Accepted Date: 2026-07-24
  • Published Date: 2026-08-25
    Abstract
  • Infection is not only a common predisposing factor for acute-on-chronic liver failure （ACLF）， but also a critical complication of ACLF， and it is closely associated with multiple organ failure and high mortality. This article systematically reviews the recent advances in the epidemiology， clinical and etiological features， pathogenesis， and diagnosis and treatment strategies of ACLF with infection， in order to provide guidance for further optimizing clinical decision-making and exploring novel diagnostic and treatment methods for such patients.

     

    • FullText(HTML)
  • loading
    • References(54)
  • [1]
    Severe Liver Disease and Artificial Liver Group, Chinese Society of Hepatology, Chinese Medical Association; Nutrition and Regeneration in End-Stage Liver Disease Group, Chinese Society of Hepatology, Chinese Medical Association. Guidelines for the diagnosis and treatment of acute-on-chronic liver failure(2025 version)[J]. J Prac Hepatol, 2025, 28( 5): 641- 647. DOI: 10.3969/j.issn.1672-5069.2025.05.001.

    中华医学会肝病学分会重型肝病与人工肝学组, 中华医学会肝病学分会终末期肝病营养与再生学组. 慢加急性肝衰竭诊治指南(2025年版)[J]. 实用肝脏病杂志, 2025, 28( 5): 641- 647. DOI: 10.3969/j.issn.1672-5069.2025.05.001.
    [2]
    Piano S, Bunchorntavakul C, Marciano S, et al. Infections in cirrhosis[J]. Lancet Gastroenterol Hepatol, 2024, 9( 8): 745- 757. DOI: 10.1016/S2468-1253(24)00078-5.
    [3]
    Wong F, Piano S, Singh V, et al. Clinical features and evolution of bacterial infection-related acute-on-chronic liver failure[J]. J Hepatol, 2021, 74( 2): 330- 339. DOI: 10.1016/j.jhep.2020.07.046.
    [4]
    Trebicka J, Fernandez J, Papp M, et al. PREDICT identifies precipitating events associated with the clinical course of acutely decompensated cirrhosis[J]. J Hepatol, 2021, 74( 5): 1097- 1108. DOI: 10.1016/j.jhep.2020.11.019.
    [5]
    Wang N, Tao S, Chen L. Construction and validation of HBV-ACLF bacterial infection diagnosis model based on machine learning[J]. BMC Infect Dis, 2025, 25( 1): 847. DOI: 10.1186/s12879-025-11199-5.
    [6]
    Thiyagarajah K, Sonnenberg J, Görgülü E, et al. Higher prevalence of cytomegalovirus and Epstein-Barr virus in acute-on-chronic liver failure[J]. JHEP Rep, 2026, 8( 4): 101627. DOI: 10.1016/j.jhepr.2025.101627.
    [7]
    Hong C Z, Huang Z X, He Y L, et al. Human cytomegalovirus reactivation in cirrhosis patients with acute decompensation[J]. Clin Mol Hepatol, 2025, 31( 4): 1316- 1332. DOI: 10.3350/cmh.2025.0332.
    [8]
    Liu Y S, Wang Q N, Huang P, et al. Phase characteristics and risk factors of acute-on-chronic liver failure with invasive pulmonary aspergillosis[J]. BMC Infect Dis, 2025, 25( 1): 1189. DOI: 10.1186/s12879-025-11518-w.
    [9]
    Xu Z, Zhang X, Chen J, et al. Bacterial infections in acute-on-chronic liver failure: Epidemiology, diagnosis, pathogenesis, and management[J]. J Clin Transl Hepatol, 2024, 12( 7): 667- 676. DOI: 10.14218/JCTH.2024.00137.
    [10]
    Barros N, Rosenblatt R E, Phipps M M, et al. Invasive fungal infections in liver diseases[J]. Hepatol Commun, 2023, 7( 9): e0216. DOI: 10.1097/HC9.0000000000000216.
    [11]
    Severe Liver Disease Group, the Professional Committee for Hepatology, Chinese Research Hospital Association; Severe Liver Diseases and Artificial Liver Group, Chinese Society of Hepatology, Chinese Medical Association. Consensus on diagnosis and treatment of invasive fungal infection in patients with severe liver disease[J]. J Clin Hepatol, 2022, 38( 2): 311- 317. DOI: 10.3969/j.issn.1001-5256.2022.02.011.

    中国研究型医院学会肝病专业委员会重症肝病学组, 中华医学会肝病学分会重型肝病与人工肝学组. 重症肝病合并侵袭性真菌感染诊治专家共识[J]. 临床肝胆病杂志, 2022, 38( 2): 311- 317. DOI: 10.3969/j.issn.1001-5256.2022.02.011.
    [12]
    Yao R Y, Xu G F, Fu X J, et al. Clinical characteristics and the role of IL-6 in acute-on-chronic liver failure patients with or without COVID-19: A multicenter paired cohort study[J]. Front Cell Infect Microbiol, 2024, 14: 1471974. DOI: 10.3389/fcimb.2024.1471974.
    [13]
    European Association for the Study of the Liver. EASL Clinical Practice Guidelines on acute-on-chronic liver failure[J]. J Hepatol, 2023, 79( 2): 461- 491. DOI: 10.1016/j.jhep.2023.04.021.
    [14]
    Piano S, Tonon M, Angeli P. Changes in the epidemiology and management of bacterial infections in cirrhosis[J]. Clin Mol Hepatol, 2021, 27( 3): 437- 445. DOI: 10.3350/cmh.2020.0329.
    [15]
    Hernández-Tejero M, Pavesi M, Aziz F, et al. Multidrug-resistant colonization in decompensated cirrhosis outside the ICU predicts infection and poor outcomes[J]. JHEP Rep, 2026, 8( 3): 101707. DOI: 10.1016/j.jhepr.2025.101707.
    [16]
    Choudhury A, Kulkarni A V, Arora V, et al. Acute-on-chronic liver failure(ACLF): The‘Kyoto consensus’-steps from Asia[J]. Hepatol Int, 2025, 19( 1): 1- 69. DOI: 10.1007/s12072-024-10773-4.
    [17]
    Zhang Q, Hu J X, Qiu S T, et al. Clinical differences between HBV and alcohol related ACLF in a WGO classification multicenter study[J]. Sci Rep, 2025, 15( 1): 25292. DOI: 10.1038/s41598-025-09620-9.
    [18]
    McGettigan B, Hernandez-Tejero M, Malhi H, et al. Immune dysfunction and infection risk in advanced liver disease[J]. Gastroenterology, 2025, 168( 6): 1085- 1100. DOI: 10.1053/j.gastro.2024.08.046.
    [19]
    Liang X, Luo J J, Zhou Q, et al. Single-cell multimodal analysis reveals the dynamic immunopathogenesis of HBV-ACLF progression[J]. Gut, 2026, 75( 2): 367- 381. DOI: 10.1136/gutjnl-2024-333308.
    [20]
    Maini A A, Becares N, China L, et al. Monocyte dysfunction in decompensated cirrhosis is mediated by the prostaglandin E2-EP4 pathway[J]. JHEP Rep, 2021, 3( 6): 100332. DOI: 10.1016/j.jhepr.2021.100332.
    [21]
    Geng A, Brenig R G, Roux J, et al. Circulating monocytes upregulate CD52 and sustain innate immune function in cirrhosis unless acute decompensation emerges[J]. J Hepatol, 2025, 83( 1): 146- 160. DOI: 10.1016/j.jhep.2024.12.031.
    [22]
    Yu X, Tian W H, Bao X W, et al. Dissecting the liver inflammation ecosystem identifies annexin A1 as a pro-resolving target for liver failure[J]. Hepatology, 2026, 83( 5): 1174- 1191. DOI: 10.1097/hep.0000000000001427.
    [23]
    Yu X P, Yang F F, Shen Z L, et al. BTLA contributes to acute-on-chronic liver failure infection and mortality through CD4+ T-cell exhaustion[J]. Nat Commun, 2024, 15( 1): 1835. DOI: 10.1038/s41467-024-46047-8.
    [24]
    Clària J, Arroyo V, Moreau R. Roles of systemic inflammatory and metabolic responses in the pathophysiology of acute-on-chronic liver failure[J]. JHEP Rep, 2023, 5( 9): 100807. DOI: 10.1016/j.jhepr.2023.100807.
    [25]
    Simbrunner B, Caparrós E, Neuwirth T, et al. Bacterial translocation occurs early in cirrhosis and triggers a selective inflammatory response[J]. Hepatol Int, 2023, 17( 4): 1045- 1056. DOI: 10.1007/s12072-023-10496-y.
    [26]
    Cao Z J, Yao Y J, Cai M H, et al. Blood markers for type-1,-2, and-3 inflammation are associated with severity of acutely decompensated cirrhosis[J]. J Hepatol, 2025, 82( 5): 836- 850. DOI: 10.1016/j.jhep.2024.10.028.
    [27]
    Trebicka J, Macnaughtan J, Schnabl B, et al. The microbiota in cirrhosis and its role in hepatic decompensation[J]. J Hepatol, 2021, 75( Suppl 1): S67- S81. DOI: 10.1016/j.jhep.2020.11.013.
    [28]
    Lee S, Arefaine B, Begum N, et al. Oral-gut microbiome interactions in advanced cirrhosis: Characterisation of pathogenic enterotypes and salivatypes, virulence factors and antimicrobial resistance[J]. J Hepatol, 2025, 82( 4): 622- 633. DOI: 10.1016/j.jhep.2024.09.046.
    [29]
    Jin S, Cenier A, Wetzel D, et al. Microbial collagenase activity is linked to oral-gut translocation in advanced chronic liver disease[J]. Nat Microbiol, 2026, 11( 1): 211- 227. DOI: 10.1038/s41564-025-02223-0.
    [30]
    Bajaj J S, Silvey S, Aljabi A, et al. Dental prophylactic interventions are associated with lower decompensation-related hospitalizations over 2 years in cirrhosis[J]. JHEP Rep, 2026, 8( 5): 101821. DOI: 10.1016/j.jhepr.2026.101821.
    [31]
    Bao Z W, Wei R N, Zheng X P, et al. Landscapes of gut microbiome and bile acid signatures and their interaction in HBV-associated acute-on-chronic liver failure[J]. Front Microbiol, 2023, 14: 1185993. DOI: 10.3389/fmicb.2023.1185993.
    [32]
    Bajaj J S, Reddy K R, O’Leary J G, et al. Serum levels of metabolites produced by intestinal microbes and lipid moieties independently associated with acute-on-chronic liver failure and death in patients with cirrhosis[J]. Gastroenterology, 2020, 159( 5): 1715- 1730. DOI: 10.1053/j.gastro.2020.07.019.
    [33]
    Chen T, Chen G, Wang G Q, et al. Expert consensus on the diagnosis and treatment of end-stage liver disease complicated by infections[J]. Hepatol Int, 2024, 18( 3): 817- 832. DOI: 10.1007/s12072-023-10637-3.
    [34]
    Xiong F X, Zheng J M, Chen J J, et al. Proteomics-based machine learning model for predicting secondary infection in HBV-related liver failure[J]. Nat Commun, 2026, 17: 3667. DOI: 10.1038/s41467-026-69075-y.
    [35]
    Juanola A, Mezzano G, Pose E, et al. PD-L1 and the risk of bacterial infection in patients with chronic liver diseases: An international multicohort study[J]. JHEP Rep, 2025, 7( 12): 101597. DOI: 10.1016/j.jhepr.2025.101597.
    [36]
    Konstantis G, Schütte A, Jung B, et al. IL-1 receptor antagonist as a diagnostic biomarker for bacterial infections in acute decompensation of cirrhosis[J]. Sci Rep, 2025, 15: 43266. DOI: 10.1038/s41598-025-30647-5.
    [37]
    Liu Y S, Zhang Q, Li J, et al. mNGS improves the efficiency of infection diagnosis and treatment in acute-on-chronic liver failure[J]. BMC Gastroenterol, 2026, 26( 1): 129. DOI: 10.1186/s12876-025-04601-8.
    [38]
    Chen J, Huang Z B, Li H, et al. Early diagnostic biomarkers of sepsis for patients with acute-on-chronic liver failure: A multicenter study[J]. Infect Dis Ther, 2021, 10( 1): 281- 290. DOI: 10.1007/s40121-020-00362-x.
    [39]
    Zhang Z W, Ma K, Yang Z Y, et al. Development and validation of a clinical predictive model for bacterial infection in hepatitis B virus-related acute-on-chronic liver failure[J]. Infect Dis Ther, 2021, 10( 3): 1347- 1361. DOI: 10.1007/s40121-021-00454-2.
    [40]
    Sun R, Lu W L, Ren W H, et al. A novel laboratory-based nomogram for assessing infection presence risk in acute-on-chronic liver failure patients[J]. Sci Rep, 2023, 13( 1): 16970. DOI: 10.1038/s41598-023-44006-9.
    [41]
    Liver Failure and Artificial Liver Group, Chinese Society of Infectious Diseases, Chinese Medical Association; Severe Liver Disease and Artificial Liver Group, Chinese Society of Hepatology, Chinese Medical Association. Guideline for diagnosis and treatment of liver failure(2024 version)[J]. J Clin Hepatol, 2024, 40( 12): 2371- 2387. DOI: 10.12449/JCH241206.

    中华医学会感染病学分会肝衰竭与人工肝学组, 中华医学会肝病学分会重型肝病与人工肝学组. 肝衰竭诊治指南(2024年版)[J]. 临床肝胆病杂志, 2024, 40( 12): 2371- 2387. DOI: 10.12449/JCH241206.
    [42]
    Lin Y X, Yu X P, Lin H M, et al. Effect of nucleos(t)ide analogues withdrawal on survival outcomes in patients with hepatitis B virus-related acute-on-chronic liver failure[J]. Aliment Pharmacol Ther, 2025, 62( 5): 504- 511. DOI: 10.1111/apt.70213.
    [43]
    Maiwall R, Piano S, Singh V, et al. Determinants of clinical response to empirical antibiotic treatment in patients with cirrhosis and bacterial and fungal infections-Results from the ICA“Global Study”(EABCIR-Global Study)[J]. Hepatology, 2024, 79( 5): 1019- 1032. DOI: 10.1097/HEP.0000000000000653.
    [44]
    Tang F J, Yuan H X, Li X H, et al. Effect of delayed antibiotic use on mortality outcomes in patients with sepsis or septic shock: A systematic review and meta-analysis[J]. Int Immunopharmacol, 2024, 129: 111616. DOI: 10.1016/j.intimp.2024.111616.
    [45]
    Kulkarni A V, Avadhanam M, Karandikar P, et al. Antibiotics with or without rifaximin for acute hepatic encephalopathy in critically ill patients with cirrhosis: A double-blind, randomized controlled(ARiE) trial[J]. Am J Gastroenterol, 2024, 119( 5): 864- 874. DOI: 10.14309/ajg.0000000000002575.
    [46]
    Verma N, Valsan A, Garg P, et al. Empirical antifungal therapy improves survival in patients with acute-on-chronic liver failure with suspected invasive fungal infections: A pragmatic randomized trial[J]. Am J Gastroenterol, 2025. DOI: 10.14309/ajg.0000000000003832.[ Epub ahead of print]
    [47]
    Prescott H C, Antonelli M, Alhazzani W, et al. Surviving Sepsis Campaign: International guidelines for management of sepsis and septic shock 2026[J]. Crit Care Med, 2026, 54( 4): 725- 812. DOI: 10.1097/CCM.0000000000007075.
    [48]
    Li J X, Xie S H, Chen M L, et al. Panose prevents acute-on-chronic liver failure by reducing bacterial infection in mice[J]. J Clin Invest, 2025, 135( 14): e184653. DOI: 10.1172/JCI184653.
    [49]
    Trebicka J, Hernaez R, Shawcross D L, et al. Recent advances in the prevention and treatment of decompensated cirrhosis and acute-on-chronic liver failure(ACLF) and the role of biomarkers[J]. Gut, 2024, 73( 6): 1015- 1024. DOI: 10.1136/gutjnl-2023-330584.
    [50]
    Korf H, du Plessis J, van Pelt J, et al. Inhibition of glutamine synthetase in monocytes from patients with acute-on-chronic liver failure resuscitates their antibacterial and inflammatory capacity[J]. Gut, 2019, 68( 10): 1872- 1883. DOI: 10.1136/gutjnl-2018-316888.
    [51]
    Xiang X G, Feng D C, Hwang S, et al. Interleukin-22 ameliorates acute-on-chronic liver failure by reprogramming impaired regeneration pathways in mice[J]. J Hepatol, 2020, 72( 4): 736- 745. DOI: 10.1016/j.jhep.2019.11.013.
    [52]
    Xiang L, An Z, Wu X Y, et al. Carbon dot-loaded apoptotic vesicles improve the liver Kupffer cell-mediated antibacterial effect to synergistically alleviate sepsis[J]. ACS Nano, 2024, 18( 26): 16726- 16742. DOI: 10.1021/acsnano.4c01780.
    [53]
    Ma C H, Zhou Y Z, Yang Z C, et al. Kupffer cells biomimetic nanoparticles alleviate sepsis related liver injury[J]. J Nanobiotechnology, 2025, 23( 1): 756. DOI: 10.1186/s12951-025-03860-7.
    [54]
    Chaudhary D, Kausar R, Lee J, et al. Bioengineered hybrid spheroids integrating mesenchymal stem cells and metformin-loaded microspheres for the treatment of sepsis-induced liver injury[J]. J Control Release, 2026, 393: 114798. DOI: 10.1016/j.jconrel.2026.114798.
    • Relative Articles
    • Supplements(0)
    • Cited By
  • 加载中

Catalog

    通讯作者: 陈斌, bchen63@163.com
    • 1. 

      沈阳化工大学材料科学与工程学院 沈阳 110142

    1. 本站搜索
    2. 百度学术搜索
    3. 万方数据库搜索
    4. CNKI搜索

    Tables(1)

    Get Citation
    PDF
    XML

    Article Metrics

    Article views (14) PDF downloads(1) Cited by()
    Proportional views
    Related
        

    The first journal specializing in hepatobiliary and pancreatic diseases in China

    Supervisor：Ministry of Education of the People's Republic of China

    Sponsor：Jilin University

    Academic Support: Chinese Society of Hepatology，Chinese Medical Association

    Address: 461 Xinjiang Road, Changchun

    Submit：0431-88782044

    Peer review：0431-88783542

    Email：lcgdb@vip.163.com

    About Journal

    Submission Guideline

    Journal Online

    Hepatobiliary College

    Guidelines

    YesterdayIP[]YesterdayPV[]TodayIP[]TodayPV[]Online[]

    Website Design © 2020 Editorial Board of Journal of Clinical Hepatology 吉ICP备10000617号-1 Supported by: Beijing Renhe Information Technology Co. Ltd  

    /

    DownLoad:  Full-Size Img  PowerPoint
    Return
    Return