Acute-on-chronic liver failure: A complex clinical entity in patients with autoimmune hepatitis

In their comprehensive and stimulating review, Moreau et al. report the distinctive features of “acute-on-chronic liver failure” (ACLF) based on different geographic definitions (European,North American, Chinese, Asian Pacific) and suggest that ACLF should be considered a unique clinical syndrome.1 However, in discussing hallmarks, causes and precipitating factors of ACLF, they do not consider the case of autoimmune hepatitis (AIH), which can initiate as acute hepatitis in more than 40% of cases.2 It is well recognized that AIH patients may develop ACLF either as hyperacute exacerbation of undiagnosed or misdiagnosed AIH, or in response to a second exogenous insult (viral, drug-induced, toxic) on typical AIH, possibly favored by long-term immunosuppression.