Clostridium perfringens is an anaerobic spore-forming bacterium capable of producing fulminant infections through potent exotoxins. We report the case of an elderly man with multiple comorbidities who presented with acute abdominal pain and vomiting. Within 24 hours, the patient developed abrupt clinical deterioration characterised by altered mental status, rapidly progressive anaemia, metabolic acidosis and multiorgan dysfunction. A CT scan demonstrated multiple gas-containing hepatic lesions without a well-defined fluid collection, compatible with emphysematous hepatitis. Blood cultures rapidly confirmed C. perfringens . Despite prompt escalation of antimicrobial therapy and intensive supportive management, the patient developed progressive multiorgan failure and died 96 hours after admission. Although C. perfringens liver abscesses associated with haemolysis have been previously described, reports combining fulminant haemolysis with a radiological pattern consistent with emphysematous hepatitis remain exceedingly rare. This case highlights the importance of early recognition of this catastrophic presentation and the need for immediate antimicrobial therapy and source control whenever feasible.

The role of human albumin therapy in the management of advanced liver disease is not yet fully established across all settings and remains a topic of debate. The significant and complicated burden of the disease, coupled with limited therapeutic options, presents ongoing challenges. At the European Association for the Study of the Liver (EASL) Congress 2026, studies in patient populations worldwide delivered new insights to add to the debate on the use of human albumin therapy at the most severe end of the liver disease spectrum. This article reviews a selection of the latest data, evaluating long-term albumin therapy for decompensated cirrhosis, as well as Phase III study evidence on the use of therapeutic plasma exchange (TPE) for acute-on-chronic liver failure (ACLF).

ABSTRACT Blood transfusions, conducted between donors compatible in their red blood cell (RBC) antigens, play a life-saving role in transfusion medicine. Genetic differences at blood group loci between ethnicities result in diversity and altered frequency of RBC antigens that need to be considered in blood transfusion. Consequently, comprehensive, and accurate blood group antigen typing is especially relevant for inter-ethnic blood transfusions and for minorities underrepresented in the donor population. Blood group microarray genotyping is a cost-efficient and scalable method for comprehensive blood group typing. Previously, however, microarray typing has been challenging for the clinically important blood group systems Rh and MNS, as these feature highly paralogous genomic loci leading to mixed signals. We here present an approach for accurately typing blood group systems, including Rh and MNS variations, that we benchmarked in an ethnically diverse cohort. We tested its performance using gold-standard, diagnostic-grade MALDI-TOF data from 1,052-samples, including 334 CEPH diversity samples and applied the approach to 4,999 samples of a COVID-19 genetics study. Overall, we obtained a 99.95% benchmarking concordance and 99.65% call rate. In summary, we provide a highly accurate and cost-efficient high-throughput genotyping method for comprehensive blood group analysis that is also suitable for ethnically diverse sample sets.

The mechanisms driving the progression from acutely decompensated (AD) cirrhosis to acute-on-chronic liver failure (ACLF), a high mortality condition, remain poorly understood. In this study, we integrate multiomics and clinical data from 766 AD patients to construct multiscale, multifactorial response networks associated with two major outcomes: ACLF development and death. Among 291 features, 22 are linked to ACLF development and 16 to mortality. These features constitute a network connecting mitochondrial dysfunction with the accumulation of the lipid mediator 20-hydroxyeicosatetraenoic acid (20-HETE). In vitro validation of this network in human peripheral leukocytes shows that 20-HETE induces mitochondrial oxidative stress and impairs mitochondrial respiration via a GPR75-Akt signaling pathway. Network features also act as early predictors of AD outcomes, a finding validated in an independent cohort of 580 patients. Here, we show a strong link between dysregulated immunomodulatory lipid mediators and mitochondrial dysfunction driving ACLF development and mortality risk in advanced cirrhosis.

Acute pancreatitis in the context of acute-on-chronic liver failure (ACLF) is a rare but potentially severe complication that can jeopardize eligibility for liver transplantation (LT). We describe two ACLF patients listed for highly prioritized transplantation who developed acute pancreatitis during the late course of ACLF. In the first case, the patient developed necrosis of the pancreatic tail and a large pseudocyst; in the second, necrosis affected >50% of the pancreatic body and tail. Both patients were delisted and died. While necrotizing pancreatitis was considered an absolute contraindication for LT in these two cases, recent reports suggest that transplantation may be feasible in highly selected patients. A case-by-case multidisciplinary assessment remains essential for appropriate decision-making in this complex scenario. Early LT could contribute to prevent this feared complication.

Acute-on-chronic liver failure (ACLF) is a severe syndrome in patients with chronic liver disease, marked by rapid multi-organ failure and high short-term mortality. Managing ACLF requires intensive care, but standardized global guidelines were previously lacking. The APASL ACLF Research Consortium (AARC) developed this position paper to establish a unified, evidence-based consensus for its critical care management. A global collaboration of 109 experts employed a systematic methodology to address key aspects of ACLF care. Sections were drafted by specialist teams, with recommendations developed using the GRADE system. Draft statements underwent iterative review and refinement, followed by an expert panel consensus process consisting of open show-of-hands voting during the APASL Annual Conference in March 2025 in Beijing and a subsequent anonymous online voting round. The consensus delivers 104 position statements. Key recommendations include using prognostic scores (AARC, CLIF-C ACLF, GIC) for ICU transfer and treatment decisions, and aggressively managing precipitating factors or complications like infections. It details organ-specific support for liver, kidney, and brain failure, advocating for early, targeted antibiotics and careful fluid management. The role of bridging therapies (plasma exchange, artificial liver systems) and nutritional support is emphasized. For transplantation, the guidelines provide criteria for patient selection and timing, particularly for alcohol-related ACLF. The APASL ACLF Beijing Position Paper provides a comprehensive, standardized framework for managing critically sick ACLF patients. Integrating multidisciplinary expertise and current evidence, these guidelines aim to optimize care, inform clinical decisions, and improve survival for this high-risk population. As a few recommendations are supported predominantly by data from different continents, they should therefore be interpreted in local contexts.

BACKGROUND AND AIMS:Cirrhosis represents the end-stage of chronic liver diseases. The ANSWER trial showed that long-term albumin (LTA) administration along with the standard medical treatment (SMT) improves survival and reduces complications in patients with decompensated cirrhosis and uncomplicated ascites. The present analysis compared the potential annual cost of treatment with LTA+SMT, following the ANSWER regimen, with respect to SMT alone in patients with decompensated cirrhosis and uncomplicated ascites from the Spanish healthcare system perspective. METHODS:Cost of illness for patients with cirrhosis and uncomplicated ascites, treated with SMT alone or LTA+SMT (ANSWER regimen), was estimated. The annual incidence of complications and treatment frequency were collected based on the findings from the ANSWER trial. Unit costs were obtained from published data and transformed to 2019 Euros. The incremental cost was the difference in annual cost per patient between LTA+SMT and SMT alone treatment groups. A univariate sensitivity analysis was performed to ensure the robustness of the analysis. RESULTS:The annual cost per patient of treatment and management of complications was estimated at €26,161 for patients treated with LTA+SMT, compared to €27,536 for those treated with SMT alone, representing saving costs of €1,375 per patient and year. CONCLUSIONS:By translating the ANSWER trial results to the Spanish clinical setting, LTA+SMT could reduce the healthcare cost associated with the management of cirrhotic patients with uncomplicated ascites due to the reduction of costly complications, which counterbalance the cost of LTA.