• Alcoholic liver disease
• histopathology
• liver failure

In patients with cirrhosis, an innocent precipitating event can often lead to acute clinical deterioration which culminates in multiple organ failure and very high rates of mortality, a condition referred to as acute-on-chronic liver failure (ACLF).1 The definition, natural history and the pathophysiological basis of this condition is being intensely discussed and studied by numerous groups across the world and has led to the development of the Asian, European and American study groups to try and answer the many questions that this intriguing condition raises.

The paper by Katoonizadeh et al2 explores the important question of the histological characteristics of this syndrome (see page 1561). In order to limit the heterogeneity, the authors appropriately limited their observations to patients with alcoholic liver disease. They included two groups of patients: an ACLF group comprising patients with underlying alcoholic cirrhosis who, within a short period of 4–8 weeks, developed end-organ dysfunction following a precipitating event; these patients were biopsied within 48–72 h of admission. The second group they studied were patients with chronic decompensated cirrhosis (CHD) who underwent liver biopsy as part of assessment for liver transplantation. The study group included 102 eligible patients (54 with ACLF and 48 with CHD). The data confirm that mortality of patients with ACLF is extremely high, with an in-hospital mortality of 46% compared with 10% for patients with CHD. The presence of clinical indicators of systemic inflammatory …