Prognostic Role of Acute-on-Chronic Liver Failure in Acute Variceal Bleeding: A Multicenter Retrospective Study in Australia

Background/Aims: Acute variceal bleeding (AVB) is a life-threatening complication of cirrhosis that can precipitate acute-on-chronic liver failure (ACLF), leading to poor outcomes. This multicenter retrospective study evaluated the impact of ACLF on the long-term outcomes of patients admitted with AVB and compared the performance of prognostic scores in predicting 1-year mortality. Methods: A total of 168 patients with cirrhosis admitted with AVB between January 2013 and December 2022 were included. ACLF was diagnosed using the Chronic Liver Failure-Consortium Organ Failure (CLIF-C OF) score at admission and reassessed at 48 hours. Prognostic scores including the Child-Pugh, AIMS65, and CLIF-C model scores were evaluated. Multivariable logistic regression analysis was performed to identify predictors of 6-week rebleeding, and Kaplan-Meier analysis was conducted to assess survival outcomes. Results: ACLF was present at admission in 21 patients (12.5%) and developed within 48 hours in two (1.2%). Although ACLF at admission was associated with a higher unadjusted 1-year mortality rate, it was not independently predictive after adjusting for hepatic reserve (Child-Pugh score) and age (hazard ratio, 0.97; 95% confidence interval, 0.32 to 2.94; p=0.951). The Child-Pugh score was the strongest predictor of the 1-year mortality rate (area under the receiver operating characteristic curve=0.718). The absence of hepatic encephalopathy independently predicted 6-week rebleeding (p=0.015). Endoscopy timing (