Alcohol Use as a Precipitant of Acute-on-Chronic Liver Failure in Non-Alcoholic Chronic Liver Disease

Background: Acute-on-chronic liver failure (ACLF) is characterized by acute deterioration in chronic liver disease (CLD), leading to organ failures. Alcohol is a major cause and trigger of ACLF, particularly in alcoholic liver disease (ALD). However, the impact of acute alcohol consumption in patients with non-alcoholic CLD (CLD-Others) is less well understood. Results: We retrospectively analyzed 623 ACLF patients, evaluating alcohol use as a sole in 19% or contributing precipitant in 39% among patients with primary CLD attributed to chronic alcohol use and those with CLD-other etiologies. Among drinkers, 225 had ALD and 134 had CLD-Others. Alcohol alone was identified as a precipitant in patients with CLD stemming from both alcoholic (ALD) and non-alcoholic etiologies (CLD-Others), and was associated with lower mortality rates at both 28 and 365 days compared to other precipitants. However, when stratified by underlying liver disease, the mortality risk associated with alcohol alone as a precipitant was significantly higher in patients with CLD-Others than in those with ALD and active alcohol use. Furthermore, when alcohol was present in conjunction with other precipitants, particularly gastrointestinal bleeding (GIB) and infections, the mortality risk was substantially elevated compared to alcohol alone, irrespective of the underlying etiology. Notably, the combination of alcohol and GIB was more frequently observed in patients with CLD-Others. Conclusions: Active alcohol use, alone or with other precipitants, increases short and long-term mortality in ACLF, with worse outcomes in CLD-Others than ALD. Distinguishing underlying liver disease etiology and precipitant patterns is vital for treatment and prognosis.