Overt hepatic encephalopathy (OHE) is a common and devastating complication of liver failure. This study aims to investigate the characteristics of OHE and its impact on outcome in patients with acute-on-chronic liver failure (ACLF), and to construct and validate a nomogram-based prediction model for OHE development. A total of 330 ACLF patients who met the World Gastroenterology Organization (WGO) criteria (ChiCTR1800017991; registered at The Third Central Hospital of Tianjin on August 25, 2018) were enrolled as a training cohort to identify the risk factors of OHE occurrence and to build an OHE model for predicting its development. Another 333 ACLF patients from a multicenter retrospective cohort in China (ChiCTR1900021539; registered at The Third Central Hospital of Tianjin on February 26, 2019) were enrolled as a validation cohort to externally validate the OHE model. Among the 330 patients in the training cohort, 158 (47.9

We describe the case of an older male patient with hepatocellular carcinoma and a history of hepatitis B virus-related cirrhosis and type 2 diabetes mellitus. At 12 weeks after treatment with transcatheter arterial chemoembolization (TACE) combined with systemic therapy using lenvatinib and camrelizumab, the patient was found to have progressive disease, based on the modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria. He also exhibited symptoms such as left eyelid ptosis and limitations in inward, upward, and downward movements of the left eye. The possibility of immune checkpoint inhibitor-induced myasthenia gravis was considered. After relevant examinations including electromyography and repetitive nerve stimulation, a diagnosis of oculomotor nerve palsy induced by diabetes-related microvascular dysfunction was ultimately considered. Subsequently, the patient was treated with camrelizumab combined with regorafenib and TACE therapy and was concurrently subjected to stricter glycemic control and neurotrophic treatment. Three months later, the ocular symptoms disappeared, and the mRECIST assessment revealed the achievement of a partial response. At the time of manuscript submission, the overall survival of the patient had reached 81 months.

Objective Acute kidney injury (AKI) is a common and life-threatening complication of liver failure. The purpose of this study is to construct a nomogram and online calculator to predict the development of hospital-acquired acute kidney injury (HA-AKI) in patients with acute-on-chronic liver failure (ACLF), which may contribute to the prognosis of ACLF. Methods 574 ACLF patients were evaluated retrospectively. AKI was defined by criteria proposed by International Club of Ascites (ICA) and divided into community-acquired and hospital-acquired AKI (CA-AKI and HA-AKI). The difference between CA-AKI and HA-AKI, factors associated with development into and recovered from AKI periods. The risk factors were identified and nomograms were developed to predict the morbidity of HA-AKI in patients with ACLF. Results Among 574 patients, 217(37.8%) patients had AKI, CA-AKI and HA-AKI were 56 (25.8%) and 161 (74.2%) respectively. The multivariate logistic regression model (KP-AKI) for predicting the occurrence of HA-AKI were age, gastrointestinal bleeding, bacterial infections, albumin, total bilirubin, blood urea nitrogen and prothrombin time. The AUROC of the KP-AKI in internal and external validations were 0.747 and 0.759, respectively. Among 217 AKI patients, 81(37.3%), 96(44.2%) and 40(18.4%) patients were with ICA-AKI stage progression, regression and fluctuated in-situ, respectively. The 90-day mortality of patients with AKI was 55.3% higher than non-AKI patients 21.6%. The 90-day mortality of patients with progression of AKI was 88.9%, followed by patients with fluctuated in-situ 40% and regression of AKI 33.3%. Conclusions The nomogram constructed by KP-AKI can be conveniently and accurately in predicting the development of HA-AKI, and AKI can increase the 90-day mortality significantly in ACLF patients. Trial registration Chinese clinical trials registry: ChiCTR1900021539.

Background and objectives:Triggering receptor expressed on myeloid cells-1 (TREM-1) is an important inflammationrelated biomarker.The present study aimed to determine whether this affects the short-term prognosis of patients with acute-chronic liver failure (ACLF).Methods: The serum sTREM-1 levels of 30 healthy subjects (HS), 40 chronic hepatitis patients without cirrhosis and liver failure (CH), 38 liver cirrhosis (LC) patients, and 59 ACLF patients were evaluated by enzyme-linked immunosorbent assay.The predictive accuracy of the logistic model for survival rate within 90 days in patients with ACLF was determined using the area under the receiver operating characteristic curve (AUC).Kaplan-Meier analysis and log-rank test were performed to revalidate the factors l for the 90-day survival rate of patients with ACLF.Results: Compared to the CH, LC and HS groups, the serum sTREM-1 levels of ACLF patients were significantly elevated (p < 0.001).In ACLF patients, the serum sTREM-1 levels further increased in non-survivors (661.51 [494.36-1,028.82]pg/mL), when compared to the survivors (440.92[308.00-523.21]pg/mL) (p = 0.002).The multivariate logistic regression analysis indicated that serum sTREM-1, sodium, and the international normalized ratio (INR) were independent predictors for the 90-day mortality of patients with ACLF.The AUC value for logit (p) in predicting the 90-day prognosis of ACLF patients was 0.89 (0.78-1.00), with a sensitivity of 70%, a specificity of 89.74%.Conclusions: Serum sTREM-1 is a valuable independent factor for determining the 90-day mortality of ACLF patients.Combining the INR and sodium in the logistic regression model may improve the accuracy in predicting the prognosis.

Objective:To investigate the clinical characteristics and risk factors for the progression of acute-on-chronic liver failure(ACLF)associated with hepatitis B in elderly patients.Methods:A total of 168 elderly patients with hepatitis B-related acute-on-chronic liver failure(HBV-ACLF)at Tianjin Third Central Hospital who met the diagnostic criteria of the Asian Pacific Association for the Study of the Liver(APASL)-ACLF were enrolled, 176 non-elderly HBV-ACLF patients served as the control group during the same period, and their baseline and progression data were recorded.At the same time, the elderly group was divided into the progressive subgroup and the non-progressive subgroup based on the diagnostic criteria of the European Society for the Study of the Liver(EASL)-ACLF, and their baseline and progression data were recorded.Independent risk factors for HBV-ACLF progression in the elderly were analyzed using multivariate Cox proportional risk model regression.Results:Compared with non-elderly patients with HBV-ACLF, elderly patients were more likely to progress to meet the EASL-ACLF diagnostic criteria and have higher mortality.Multivariate Cox proportional risk model regression analysis showed that baseline arterial lactic acid levels( HR=1.77, 95% CI: 1.36-2.30, P<0.01), secondary nosocomial infections( HR=13.90, 95% CI: 3.73-51.87, P<0.01), rates of change in maximum total bilirubin( HR=1.08, 95% CI: 1.01-1.15, P=0.04), rates of change in maximum MELD( HR=4.06, 95% CI: 1.53-10.77, P=0.01)and rates of change in maximum CLIF-SOFA( HR=12.74, 95% CI: 2.46-66.08, P<0.01)were independent risk factors for progression of HBV-ACLF in elderly patients. Conclusions:Compared with non-elderly patients, elderly patients with HBV-ACLF have more advanced disease and higher mortality.Therefore, risk factors should be identified as soon as possible and treatment plans should be formulated as soon as possible to further reduce the mortality.

Objective:To analyze the predictive ability of model for end-stage liver disease (MELD)-sarcopenia score in short-term prognosis of patients with acute-on-chronic liver failure (ACLF).Methods:Two hundred and seventy-one patients with ACLF hospitalized in Tianjin Third Central Hospital from January 2013 to December 2019 were selected, among whom 157 cases with sarcopenia and 114 cases without sarcopenia.According to ACLF classification, the patients were divided into group A (no cirrhosis basis) of 61 cases, group B (compensated cirrhosis basis) of 99 cases, and group C (previous history of uncompensated cirrhosis) of 111 cases.The basic data, laboratory examination results, computed tomography (CT) examination results and prognosis of the patients were retrospectively collected, and the MELD score, MELD-Na score and MELD-sarcopenia score were calculated. Multivariate logistic regression, multivariate Cox proportional hazards regression, Kaplan-Meier method, log-rank method and area under receiver operating characteristic curve were used for statistical analysis.Results:Low body mass index (odds ratio ( OR)=0.93, P<0.001), complicated cirrhosis ( OR=1.14, P=0.004), complicated hepatic encephalopathy ( OR=1.31, P<0.001), high white blood cell level ( OR=1.18, P=0.009) and high platelet level ( OR=1.08, P<0.001) were independent risk factors for sarcopenia in patients with ACLF. High MELD score (hazard ratio ( HR)=1.02, P=0.001), high MELD-Na score ( HR=1.07, P=0.038), high MELD-sarcopenia score ( HR=1.14, P<0.001), high total bilirubin ( HR=1.00, P<0.001) and high international normalized ratio (INR) ( HR=1.71, P<0.001) were independent risk factors for death in patients with ACLF. In subgroup analysis, the cumulative survival rate of sarcopenia patients in group A and B was lower than that of non-sarcopenia patients ( χ2=5.97 and 8.34, respectively, P=0.015 and 0.004, respectively), while there was no significant difference in the cumulative survival rate between sarcopenia patients and non-sarcopenia patients in group C ( χ2=4.90, P=0.053). In groups A and B, the area under the curve (AUC) of MELD-sarcopenia score in predicting short-term prognosis was 0.87, which was higher than MELD score (0.78) and MELD-Na score (0.78), and the differences were both statistically significant ( Z=2.86 and 2.56, respectively, P=0.004 and 0.011, respectively). The AUC of MELD-Na score in predicting short-term prognosis in group C (0.83) was higher than that of MELD score (0.71) and MELD-sarcopenia score (0.69), and the differences were both statistically significant ( Z=2.52 and 2.64, respectively, P=0.012 and 0.008, respectively). Conclusions:Patients with ACLF with no cirrhosis basis or compensated cirrhosis basis complicated with sarcopenia have shorter survival time and worse prognosis than those without sarcopenia. For patients with ACLF with no cirrhosis basis or compensated cirrhosis basis, MELD-sarcopenia score has better predictive value for the short-term prognosis.

背景 肌肉减少症是终末期肝病患者死亡的独立危险因素,与患者的预后密切相关,因此受到广泛关注.但对于肌少症来说,目前还缺乏统一的检测方法和诊断标准,临床应用受限.目的评估乙肝肝硬化相关慢加急性肝衰竭(acute-on-chronic liver failure,ACLF)患者的第三腰椎腰大肌指数(the third lumbar level psoas muscle index,L3-PMI)与临床指标的关系及其在预后评估中的作用.方法 采用回顾性研究的方法,选取2014-01/2017-12在天津市第三中心医院肝内科住院的符合乙肝肝硬化相关ACLF诊断标准且有腹部CT扫描资料的140例患者为研究对象.由同一名研究者在患者腹部CT图像上手动追踪第三腰椎下缘水平面,测量双侧腰大肌最大前后径和横径,计算腰大肌指数.分析患者的L3-PMI和临床特点及预后.结果 将140例患者按90天生存情况分为生存组102例,死亡组38例.死亡组患者L3-PMI值4.89 cm2/m2±1.42 cm2/m2较生存组患者5.94 cm2/m2±1.24 cm2/m2显著降低(P＜0.001);血小板(platelet,PLT)、白蛋白(albumin,ALB)、丙氨酸转移酶(alanine aminotransferase,ALT)、天门冬氨酸转移酶(aspartate transaminase,AST)、血肌酐(serum creatinine,SCr)、估算肾小球滤过率(estimated glomerular filtration rate,eGFR)在两组之间无统计学差异,P值均＞0.05;死亡组患者白细胞(white blood cell,WBC)、国际标准化比值(international normalized ratio,INR)水平、终末期肝病模型(model for end-stage liver disease,MELD)评分显著高于生存组,而血清钠显著低于生存组(P值均＜0.05).此外,ACLF患者中33例合并肝性脑病(hepatic encephalopathy,HE)的患者L3-PMI值5.17 cm2/m2±1.49 cm2/m2显著低于107例未合并HE的患者5.80 cm2/m2±1.29 cm2/m2,(P=0.02).所有ACLF患者中男性120例,女性20例,其中男性组L3-PMI值5.92 cm2/m2±1.23 cm2/m2显著高于女性组4.03 cm2/m2±0.92 cm2/m2,(P＜0.05).按性别分别绘制L3-PMI预测死亡的ROC曲线图,其中男性ROC曲线下面积0.726,截断值为5.02,敏感度为85％,特异度50％;女性ROC曲线下面积0.774,截断值为4.60,敏感度为50％,特异度100％.结论 L3-PMI对于评估乙肝肝硬化相关ACLF患者的预后有重要临床应用价值.

慢性肾脏病(CKD)患者常合并高血压,而高血压又是促进CKD发展的重要危险因素,控制高血压是阻断CKD进展的关键之一.自2012版《KDIGO临床实践指南:慢性肾脏病患者的血压管理》发布以来,新的临床试验证据不断涌现.基于此,KDIGO发布了2021版更新指南.新版指南涵盖标准的诊室血压测量、非透析CKD患者的生活方式干预、血压管理和用药建议,并推荐对特殊CKD人群(包括肾移植患者和儿童)加强血压管理.与前版指南相比,标准的诊室血压测量为新增加的内容,而最值得关注的是,指南建议未接受透析的CKD患者血压靶目标值应控制在收缩压<120 mmHg,进一步体现了强化降压的获益,但推荐等级仅为2B.该文就以上几个方面的内容对该共识展开解读.

随着社会和经济的发展,人们健康意识逐渐提高,体检也被更多人提上日程安排.在健康体检中,腹部超声作为最常见的项目之一,"肝囊肿"的检出率也愈发升高,已报道的患病率从2.5％-18％不等.不少人看到囊肿的"肿"字不免有点慌神:肝囊肿是肿瘤吗?严重吗?需要手术吗?要想不害怕,就应该知己知彼,下面就让我们来谈一谈这个常见的肝脏占位性病变.

Introduction: Although the current western treatment plans for unstable angina (UA) has been optimized in past decades, UA still is a common phenotype of acute coronary syndrome and significantly influence the quality of life and endanger lives. In China, the clinical application of Chinese herb medicine is considered as an effective approach to treating UA and widely recognized by patients. In clinical practices, we found Luofengning granule (LFN-G) could improve clinical manifestations of patients with UA, but there is lack of rigorous proof of evidence-based medicine. This trial aims to further evaluate the efficacy of LFN-G in the treatment of UA. Methods: A prospective, open-label, randomized, placebo-controlled clinical will be performed. A total of 60 patients diagnosed with UA will be randomly allocated to either the treatment group or the control group with a 1:1 ratio. The participants in the treatment group will receive LFN-G treatment and the participants in the control group will receive placebo. Meanwhile, both groups continue to undergo standard western medicine treatments. The duration of interventions is 4 weeks. The primary endpoint is the incidence of major cardiac adverse events, defined as a composite of recurrent angina, acute myocardial infarction (AMI), severe arrhythmia, heart failure, and cardiac death. Secondary outcomes include Seattle angina scale score, Chinese medicine syndromes and electrocardiograph (at weeks 0, 1, 2, 4), myocardial nuclides perfusion, measurement of wall motion score index and left ventricular ejection fraction, serum inflammation factors such as C-reactive protein, high sensitive-C-reactive protein, interleukin-6, matrix metalloproteinase-9, and so on (at weeks 0, 4). In addition, some biochemical indexes of blood and hematological indexes will be used to assess the safety of treatments. Any adverse effects of the treatment will be recorded. Discussion: The results of this trial will provide compelling evidence of the efficacy and safety of LFN-G for treatment of UA and preliminarily reveal the potential mechanism of how LFN-G acts. Finally, it will widen treatment options for patients with UA.

Abstract Background: Drug-coated balloons (DCB) have been a novel alternative therapeutic strategy in de novo coronary artery diseases. However, the clinical feasibility of the DCB-only approach in treating small vessel disease remains controversial, while study aimed to assess the efficacy and safety of the DCB-only approach versus stent approaches in treating large vessel disease is limited. Methods: From February 2020 to May 2020, we will search Cochrane Library, PubMed, EMBASE, ScienceDirect, Scopus, Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, and Chongqing VIP Database for eligible trials comparing DCB with drug-eluting stents for treatment of de novo lesions in both small vessel disease and large vessel disease. The primary endpoint is major adverse cardiac events (MACE); the secondary endpoints include in-lesion late lumen loss, binary restenosis, myocardial infarction, target lesion revascularization (TLR), mortality and target vessel thrombosis. Meta-analysis will be conducted using Review Manager software (V.5.3). Results: The results will be presented as risk ratios for dichotomous data, and weighted mean differences for continuous data. Conclusion: We will assess outcomes of the DCB-only approach in the treatment of de novo lesions compared with the stent approach. PROSPERO registration number: CRD42020164484.

BACKGROUND:Drug-coated balloons (DCB) have been a novel alternative therapeutic strategy in de novo coronary artery diseases. However, the clinical feasibility of the DCB-only approach in treating small vessel disease remains controversial, while study aimed to assess the efficacy and safety of the DCB-only approach versus stent approaches in treating large vessel disease is limited. METHODS:From February 2020 to May 2020, we will search Cochrane Library, PubMed, EMBASE, ScienceDirect, Scopus, Chinese Biomedical Literature Database, Chinese National Knowledge Infrastructure (CNKI), Wanfang Database, and Chongqing VIP Database for eligible trials comparing DCB with drug-eluting stents for treatment of de novo lesions in both small vessel disease and large vessel disease. The primary endpoint is major adverse cardiac events (MACE); the secondary endpoints include in-lesion late lumen loss, binary restenosis, myocardial infarction, target lesion revascularization (TLR), mortality and target vessel thrombosis. Meta-analysis will be conducted using Review Manager software (V.5.3). RESULTS:The results will be presented as risk ratios for dichotomous data, and weighted mean differences for continuous data. CONCLUSION:We will assess outcomes of the DCB-only approach in the treatment of de novo lesions compared with the stent approach. PROSPERO REGISTRATION NUMBER:CRD42020164484.

BACKGROUND:Hyperkalemia is a serious complication in cirrhotic patients. However, the clinical characteristics, risk factors, and its impact on the outcomes in acute-on-chronic liver failure (ACLF) patients remain unclear.METHODS:We retrospectively recruited 650 ACLF patients in this study. The risk factors associated with hyperkalemia and its relationship with 90-day mortality were analyzed using multivariable regression models.RESULTS:Among 650 patients with ACLF, 12.2% (79/650) had hyperkalemia during hospitalization. Higher admission serum potassium levels and the presence of acute kidney injury (AKI) were independent risk factors for hyperkalemia. The prevalence rates of hyperkalemia in patients with and without AKI were 23.6% and 4.6%, respectively (P<0.001). Hyperkalemia was a predictor of mortality in AKI and non-AKI patients. The 90-day mortality rates in non-AKI patients with and without hyperkalemia were 44.4% and 24.7%, respectively (P<0.001), and in AKI patients with and without hyperkalemia were 80.3% and 56.6%, respectively (P<0.001). Hepatic encephalopathy (HE), gastrointestinal bleeding, AKI, hyperkalemia, elevated total bilirubin (TBIL) and international normalized ratio (INR) values, and higher Model for End-Stage Liver Disease (MELD) and chronic liver failure-sequential organ failure assessment (CLIF-SOFA) scores were independent risk factors for predicting the 90-day mortality in ACLF patients.CONCLUSIONS:Hyperkalemia increases the 90-day mortality in ACLF patients; hyperkalemia is associated with AKI. Patients with both AKI and hyperkalemia had the worst outcome.

目的 旨在探讨红细胞分布宽度(RDW)在慢加急性肝衰竭(ACLF)患者预测预后中的应用.方法 选取乙型肝炎病毒(HBV)相关性ACLF患者78例,根据预后分为生存及死亡组,检测患者外周血RDW水平及其他相关临床指标.结果 ACLF死亡患者外周血RDW水平高于生存患者(t=-3.568,P=0.004).RDW与白细胞计数(WBC)、中性粒细胞绝对值/淋巴细胞绝对值(NLR)、总胆红素(TBIL)、终末期肝脏病评分(MELD)存在相关性(P值均<0.05).受试者工作特征曲线(ROC)分析显示:RDW预测ACLF死亡率的ROC曲线下面积(AUC)为0.64,Cut-off值为17.15％,灵敏度和特异度分别为54.2％ 和67.9％.多因素回归分析显示:RDW、NLR、国际标准化比值(INR)是ACLF患者短期死亡率的独立危险因素(OR值=1.444、1.305、1.891,P值均<0.05),生存分析显示:RDW≥17.15％患者生存率低于RDW<17.15％患者(P<0.05).结论 外周血RDW是临床预测ACLF患者短期预后的简单、有效的指标.

肝肾综合征(HRS)是晚期肝硬化患者的极危重并发症,患者肾脏无明显器质性病变,是以肾功能损伤、血流动力学改变和内源性血管物质异常为特征的一种综合征.HRS显著增加肝硬化患者病死率.其早期诊断和及时治疗对降低病死率、改善预后至关重要.目前,HRS的诊断主要以血肌酐标准为主.肝移植仍是解决HRS最根本的治疗手段.未来仍需对HRS的基础与临床方面努力专研,以求突破.

Systemic inflammatory responses are associated with the development and progression of liver failure. Neutrophil-to-lymphocyte ratio (NLR), monocyte-to-lymphocyte ratio (MLR), platelet-to-lymphocyte ratio (PLR), prognostic nutritional index (PNI), red cell distribution width (RDW), RDW-to platelet ratio (RPR), mean platelet volume (MPV), and MPV-to platelet ratio (MPR) are markers of systemic inflammation. This study aimed to evaluate the prognostic values of these inflammatory markers in patients with hepatitis B virus-related acute-on-chronic liver failure (HBV-ACLF). 203 HBV-ACLF patients, 79 cirrhosis patients (LC), 63 chronic hepatitis B (CHB), and 81 healthy subjects (HS) participated in this cohort study. Complete blood counts and biochemical examinations were obtained after overnight fasting. Multivariate analyses of 90-day outcome predictors were analyzed by Cox regression models. Survival probability curves were calculated by the Kaplan Meier method. The levels of NLR, MLR, RDW, MPV, RPR, and MPR were significantly higher and PNI was lower in patients with liver failure at presentation compared to those in LC, CHB, and HS (P<.001). In acute-on-chronic liver failure (ACLF) patients, NLR and MLR were higher in nonsurvivors than in survivors (P<.001), while other inflammatory markers showed no difference. ROC curve analyses showed that NLR combined with MLR had the highest AUC for identified poor outcome, followed by NLR, chronic liver failuresequential organ failure assessment (CLIF-SOFA), MLR, model for end-stage liver disease (MELD), Child-Turcotte-Pugh (CTP) and TBIL. Multivariate analyses showed that TBIL, NLR, CTP, MELD, and CLIF-SOFA were independent predictors for 90-day mortality. Combination of NLR and MLR are more accurate prognostic markers for predicting poor outcome than either marker alone in ACLF patients. And this combination is superior to the CLIF-SOFA, MELD, CTP score, and TBIL in terms of prognostic ability.

AIM To compare the performance of age,bilirubin,INR,and creatinine(ABIC),Maddrey’s discriminant function(MDF),model for end-stage liver disease(MELD),chronic liver failure-sequential organ failure assessment(CLIF-SOFA),and Child-Turcotte-Pugh(CTP) in predicting short-term mortality in patients with alcohol-related acute-on-chronic liver failure(ACLF).METHODS There were 462 consecutive patients with live failure treated from August 2005 to June 2017 at Tianjin Third Central Hospital,of whom 152 with alcohol-related ACLF were finally enrolled in this study according to the inclusion criteria and exclusion criteria.We divided patients into either group A or group B.Patients in group A met the criteria of Asian Pacific Association for the Study of the Liver but did not met the criteria of European Association for the Study of the LiverChronic Liver Failure(EASL-CLIF),and patients in group B met the criteria of EASL-CLIF on admission.The performance of different scoring models in predicting short-term mortality was assessed using the area under the receiver operating characteristic curve(AUC-ROC).RESULTS The 28-d mortality rate was 19% in group A and 50% in group B(P = 0.002).In group A,the AUC of CLIFSOFA for predicting the 28-d mortality was highest(0.889),followed by MELD(0.761),MDF(0.738),ABIC(0.718),and CTP(0.671),and the rewas a significant difference between CTP and the others.In group B,the AUC of CLIF-SOFA was 0.916,followed by MELD(0.804),MDF(0.770),ABIC(0.729),and CTP(0.647),and there was a signifi cant difference between CLIF-SOFA and the others and between CTP and the others.CONCLUSION The five scoring systems could all predict the shortterm prognosis of the two groups of patients.However,CLIF-SOFA performs well compared to the others,regardless of patients in group A or group B.

Abstract Bacterial infections are an important cause of mortality in liver failure. However, the type of infection, predictors of infection, and their impact on outcomes in patients with acute-on-chronic liver failure (ACLF) are limited. A total of 389 patients with ACLF were admitted in this retrospective, corhort study. Once admitted, clinical data including first infection site, type (community-acquired, healthcare-associated, or nosocomial), and second infection occurrence during hospitalization were collected. The outcome was mortality within 90 days. Multivariable logistic regression models were preformed to predict second infection development and 90-day mortality. Survival probability curves were calculated by the Kaplan–Meier method. Among 389 patients, 316 (81.2%) patients had infection. The 90-day mortality of patients with and without infection was 52.2% and 16.4%, respectively (P <.001). The most common first infection was healthcare associated (51.3%), followed by nosocomial (30.1%) and community-acquired infections (18.7%). Respiratory tract infection, spontaneous bacterial peritonitis, and urinary tract infection were most prevalent. Gram-positive organism was more frequently seen than gram-negative organisms. Of note, fungi accounted for 15.9% of the total infection cases. During hospitalization, 26.6% patients developed second infections. The 90-day mortality of patients developed or did not develop a second infection were 67.9% and 46.6%, respectively (P <.001). Independent predictors of 90-day mortality in infected patients with ACLF were age, white blood cell (WBC) count, model for end-stage liver disease (MELD) score, hepatic encephalopathy (HE), and second infection. Infections (regardless of first or second infection) can increase the 90-day mortality significantly in patients with ACLF. And age, WBC count, MELD score, HE, and the presence of second infection are independent risk factors affecting 90-day mortality in patients with ACLF showing infection.