In 2025， Severe Liver Disease and Artificial Liver Group and Nutrition and Regeneration in End-Stage Liver Disease Group of Chinese Society of Hepatology， Chinese Medical Association， convened a panel of national experts to jointly develop China’s first guideline for the diagnosis and treatment of acute-on-chronic liver failure （ACLF）. Based on the latest research findings and clinical practice in China and globally， this guideline establishes a standardized definition of ACLF and provide recommendations for its diagnosis， treatment， and clinical management. This article gives an interpretation of the key points in the guideline， in order to provide a reference for standardized diagnosis and treatment of ACLF.

ObjectiveTo investigate the dynamic trajectories of prognostic scores and key clinical indicators in hepatitis B virus-related acute-on-chronic liver failure （HBV-ACLF） patients without liver cirrhosis， to clarify their association with outcomes， and to provide new evidence for individualized prognostic assessment. MethodsA prospective study was conducted for the data of 154 non-cirrhotic HBV-ACLF patients who attended Beijing YouAn Hospital of Capital Medical University from January 2016 to December 2023， including prognostic scores and key biochemical indicators on Days 3， 7， 14， 21， and 28 of the disease course. According to the outcome of patients at 1 year， they were divided into death/liver transplantation group with 43 patients， liver cirrhosis group with 23 patients， and non-liver cirrhosis group with 88 patients， and the trajectory heterogeneity of different outcome subgroups was analyzed. A one-way analysis of variance was used for comparison of normally distributed continuous data among the three groups； the Kruskal-Wallis H test was used for comparison of non-normally distributed continuous data among the three groups； the Wilcoxon test was used between two groups. the chi-square test was used for comparison of categorical data between groups. The mean and its 95% confidence interval （CI） were calculated for each indicator at difference time points； the linear interpolation method was used to connect the means at adjacent time points and construct the group-specific longitudinal trend curve； the 95%CI was visualized using the semi-transparent ribbon area， with the transparency parameter （α=0.2） optimized to enhance the visual discrimination of overlapping intervals across multiple groups. A linear mixed-effects model was used to compare the longitudinal changing trend of each indicator between the patients with different outcomes； likelihood ratio was used to evaluate the significance of the interaction effect between time and group， and in case of the significant interaction effect， the slope based on the estimated marginal mean was used for comparison between two groups. ResultsThere were significant differences between the three groups in the incidence rates of ascites and grade Ⅲ — Ⅳ hepatic encephalopathy， MELD score， MELD-Na score， CLIF-C ACLF score， COSSH-ACLF Ⅱ score， total bilirubin （TBil）， international normalized ratio （INR）， alpha-fetoprotein， blood sodium， alanine aminotransferase， and procalcitonin at the baseline（all P0.05）. The analysis of dynamic trajectories showed that the death/liver transplantation group had high levels of prognostic scores and the biochemical parameters of TBil and INR （TBil400 μmol/L， INR2.5）， as well as a low level of platelet count （PLT） （100×10⁹/L）. The non-liver cirrhosis group had rapid improvements in indicators， with TBil200 μmol/L， INR1.5， and PLT100×10⁹/L by day 28， while the liver cirrhosis group showed a trend of recovery， with TBil200 μmol/L， INR2.0， and PLT 100×10⁹/L on day 28， with significant global heterogeneity in the temporal trends of the above indicators across the three groups （all P0.01）. ConclusionDynamic monitoring of prognostic scores and key clinical indicators can effectively stratify the 1-year outcomes of non-cirrhotic patients with HBV-ACLF. Patients with poor prognosis were typically characterized by INR 2.5 and TBil 400 μmol/L. Among those who survived beyond 1 year， individuals who subsequently progressed to cirrhosis were frequently identified by the presence of INR 1.5， TBil 200 μmol/L， and PLT 100×10⁹/L at day 28.

ObjectiveTo investigate the characteristics of intrahepatic and extrahepatic organ failure at the onset of acute－on－chronic liver failure（ACLF）， to explore the features of a new clinical classification system of ACLF， and to provide a basis for the diagnosis， treatment， prognostic analysis of the disease. MethodsA retrospective analysis was performed for the clinical data of the patients who were hospitalized Beijing YouAn Hospital， Capital Medical University， from January 2015 to October 2022 and were diagnosed with ACLF for the first time. According to the conditions of intrahepatic and extrahepatic organ failure at disease onset， they were classified into type Ⅰ ACLF and type Ⅱ ACLF. Type Ⅰ ACLF referred to liver failure on the basis of chronic liver diseases， and type Ⅱ ACLF referred to acute decompensation of chronic liver diseases combined with multiple organ failure. The clinical features of patients with type Ⅰ or type Ⅱ ACLF were analyzed， and the receiver operating characteristic （ROC） curve was used to assess the value of MELD， MELD－Na， and CLIF－C ACLF scoring system in predicting the 90－day prognosis of ACLF patients with type Ⅰ or type Ⅱ ACLF. The independent－samples t test was used for comparison of normally distributed continuous data between two groups， and the Wilcoxon rank－sum test was used for comparison of non－normally distributed continuous data between two groups； the chi－square test or the Fisher’s exact test was used for comparison of categorical data between two groups. ResultsA total of 582 patients with ACLF were enrolled， among whom there were 535 patients with type Ⅰ ACLF and 47 patients with type Ⅱ ACLF. Hepatitis B and alcoholic liver disease were the main causes in both groups， with no significant difference between the two groups （P>0.05）. Chronic non－cirrhotic liver disease （28.2%） and compensated liver cirrhosis （56.8%） were the main underlying liver diseases in type Ⅰ ACLF， while compensated liver cirrhosis （34.0%） and decompensated liver cirrhosis （61.7%） were the main underlying liver diseases in type Ⅱ ACLF， and there was no significant difference in underlying liver diseases between the patients with type Ⅰ ACLF and those with type Ⅱ ACLF （P<0.001）. The patients with type Ⅱ ACLF had significantly higher median MELD score， MELD－Na score， and CLIF－C ACLF score than those with type Ⅰ ACLF （all P<0.001）. The patients with type Ⅱ ACLF had significantly higher 28－ and 90－day mortality rates than those with type Ⅰ ACLF （38.3%/53.2% vs 15.5%/27.5%， P<0.001）. For the patients with type Ⅰ ACLF who did not progress to multiple organ failure， the patients with an increase in MELD score accounted for 63.7% in the death group and 10.1% in the survival group （P<0.001）， while for the patients with type Ⅰ ACLF who progressed to multiple organ failure， there was no significant difference in the change in MELD score between the survival group and the death group （P>0.05）. In the patients with type Ⅰ ACLF， MELD score， MELD－Na score， and CLIF－C ACLF score had an area under the ROC curve （AUC） of 0.735， 0.737， and 0.740， respectively， with no significant difference between any two scores （all P>0.05）. In the patients with type Ⅱ ACLF， CLIF－C ACLF score had a significantly higher AUC than MELD score （0.880 vs 0.560， P<0.01） and MELD－Na score （0.880 vs 0.513， P<0.01）. ConclusionThere are differences in underlying liver diseases， clinical features， and prognosis between type Ⅰ and type Ⅱ ACLF， and different prognosis scoring systems have different emphases， which provide a basis for the new clinical classification system of ACLF from the perspective of evidence－based medicine.

Hepatitis D virus (HDV) needs hepatitis B virus (HBV) as a helper to infect hepatocytes and spread. Co-infection with HDV and HBV may lead to accelerated progression and poor prognosis, but at present, the hazard and disease burden of HDV infection have been severely underestimated. This article summarizes the research advances in the epidemiology, clinical manifestations, diagnosis, and treatment of HDV infection, in order to provide a reference for more clinicians.

Objective To investigate the influence of intrahepatic cholestasis of pregnancy (ICP) on adverse pregnancy outcomes of hepatitis B virus (HBV)-infected pregnant women. Methods A retrospective analysis was performed for 232 pregnant women with chronic HBV infection who were admitted to Beijing YouAn Hospital, Capital Medical University, from March 2018 to March 2021. According to the presence or absence of ICP, the patients were divided into HBV infection group with 100 patients and HBV+ICP group with 132 patients; according to the severity of ICP, the patients in the HBV+ICP group were further divided into HBV+mild ICP group with 86 patients and HBV+severe ICP group with 46 patients. The above groups were compared in terms of the incidence rates of maternal complications during pregnancy, such as premature delivery, premature rupture of membranes, gestational diabetes mellitus, hypertensive disorder complicating pregnancy, and postpartum hemorrhage (PPH), as well as the adverse outcomes of fetus/neonate, such as intrauterine fetal death, neonatal asphyxia, amniotic fluid pollution degree Ⅲ(AFⅢ), neonatal respiratory distress syndrome, small-for-gestational-age (SGA), admission to the neonatal intensive care unit, pneumonia, and mother-to-child transmission (MTCT) of HBV. A one-way analysis of variance was used for comparison between multiple groups; the chi-square test, the chi-square test with continuity correction or the Fisher's exact test was used for comparison of categorical data between multiple groups. Results Compared with the HBV infection group in terms of maternal complications in late pregnancy, the HBV+ICP group had significantly higher incidence rates of premature delivery and PPH ( χ 2 =4.169 and 5.448, P =0.041 and 0.020), and in terms of the adverse outcomes of neonates, the HBV+ICP group had significantly higher incidence rates of neonatal asphyxia, AFⅢ, and SGA than the HBV infection group ( χ 2 =5.448, 16.567, and 11.053, P =0.020, P < 0.001, and P =0.002). In terms of the adverse outcomes of neonates, the HBV+severe ICP group had significantly higher incidence rates of AFⅢ and SGA than the HBV+mild ICP group ( χ 2 =4.200 and 4.511, P =0.040 and 0.034). Conclusion Compared with the pregnant women with HBV infection alone, the pregnant women with HBV infection and ICP have significantly higher incidence rates of adverse pregnancy outcomes in mothers and neonates, and the incidence rate of adverse outcomes in neonates increases with the increase in the severity of ICP. However, ICP has no influence on HBV MTCT.

Objective To investigate the factors for gestational diabetes mellitus (GDM) in pregnant women with chronic hepatitis B virus (HBV) infection, their pregnancy outcome, and related influence on neonates. Methods A retrospective analysis was performed for 317 pregnant women with chronic HBV infection who were treated, gave birth, and were followed up in Beijing YouAn Hospital, Capital Medical University, from January to December 2017, and according to the presence or absence of GDM, they were divided into chronic HBV+GDM group and chronic HBV control group. Related data were recorded, including HBV serology, liver function, HBV DNA quantification, pregnancy comorbidities, mode of delivery, and the condition of neonates at birth. The t -test or t ′-test was used for comparison of normally distributed continuous data between two groups, and the Mann-Whitney U test was used for comparison of non-normally distributed continuous data between two groups; the chi-square test or the Fisher's exact test was used for comparison of categorical data between two groups; a binary logistic regression analysis was used to investigate the risk factors for GDM in mothers with chronic HBV infection. Results Among the 317 mothers, 64 (20.19%) had chronic HBV infection and GDM, and there were 253 mothers (79.81%) in the control group. Compared with the control group, the chronic HBV+GDM group had significantly higher age ( Z =-2.652, P < 0.05), baseline alanine aminotransferase ( Z =-4.393, P < 0.05), baseline aspartate aminotransferase ( Z =-2.457, P < 0.05), and HBV DNA quantification ( P < 0.05). The logistic regression analysis showed that HBV DNA quantification (odds ratio [ OR ]=23.40, 95% confidence interval [ CI ]: 7.10-77.14, P < 0.001) and old age ( OR =10.10, 95% CI : 1.02-1.17, P =0.01) were independent risk factors for GDM in pregnant women with chronic HBV infection. The pregnant women with chronic HBV infection and GDM were more likely to experience premature rupture of membranes during delivery ( χ 2 =4.514, P =0.034), and the neonates born to these women were more likely to experience preterm birth ( χ 2 =9.293, P =0.002) and fetal intrauterine distress ( P =0.018). Conclusion HBV DNA quantification and old age are risk factors for GDM in mothers with chronic HBV infection, and GDM in pregnant women with chronic HBV infection may increase the incidence rate of premature rupture of membranes, fetal intrauterine distress, and premature delivery.

In pregnant women with hepatitis B virus (HBV) infection, body changes (hormone levels and immune status) during pregnancy or drug withdrawal after antiviral therapy may lead to virological changes, abnormal liver function, and even adverse outcomes in severe cases. Therefore, strengthening the monitoring of virological indicators and liver function in pregnant women with chronic HBV infection during pregnancy and after delivery can help to find body changes in time and thus prevent the adverse outcomes such as hepatitis and liver failure. This article reviews the articles on the characteristics and mechanisms of virological and liver function changes in pregnant women with chronic HBV infection during pregnancy and after delivery, in order to provide theoretical support for clinicians on the management of pregnant women with chronic HBV infection during pregnancy and after delivery.

Objective To investigate the effect of epidermal growth factor (EGF) on the expression of Matrix metalloproteinase-9 (MMP-9) and the signalling pathways involved in the trophoblast cell line JEG-3. Methods The JEG-3 trophoblast cell line was used in this study. (1) JEG-3 cells were cultured with various concentrations of EGF (0, 1, 10,20 ng/ml) for 24 hours and the expression of MMP-9 was tested by western blotting and reverse transcription PCR (RT-PCR). (2) Western blotting and RT-PCR were also used to investigate the expression of MMP-9 expression after incubation for 0,4,12 and 24 hours with EGF treatment (10 ng/ml) in JEG-3 cells. (3) According to the different added ingredients, JEG-3 cells were divided into some groups: control group (without EGF), EGF group (exposure to l0ng/ml EGF),EGF + inhibitors group (exposure to 10 ng/ml EGF +20 ng/ml SB203580 or exposure to 10 ng/ml EGF + 10ng/ml U0126) inhibitors group (exposure to 20 ng/ml SB203580 or exposure to 10 ng/ml U0126). Western blotting were used to investigate the expression levels of MMP-9, nuclear factor kappa B (NF-kB) ,p38MAPK, phospho-p38MAPK (p-p38MAPK) , extracellular -signal regulated kinase (ERK) and phospho-ERK (p-ERK) protein in JEG-3 cells after incubation for 24 hours. Results (1) The profiles of MMP-9mRNA were increased by various concentrations of EGF (0, 1 , 10, 20 ng/ml) in JEG-3 cells after 24hculture. The expression of MMP-9 mRNA in JEG-3 cells exposure at 1 ng/ml of EGF (0. 567 ±0. 056) , 10ng/ml of EGF (1. 392 ±0. 133) , 20 ng/ml of EGF (1. 971 ±0. 067) were significantly higher respectively (P <0. 05) , compared with 0 ng/ml of EGF treatment (0. 166 ±0. 015). Similarly, MMP-9 mRNAs were also increased with the increasing incubation time. Compared to EGF (10 ng/ml) stimulation for 0 h (0.253 ±0.044), the MMP-9 mRNA profiles were 0. 470 ±0. 026, 1.061 ±0. 115, 1. 453 ±0. 180 for 4,12 and 24 hours, respectively (P < 0. 05). (2) In accordance to the mRNA profiles, the expression of MMP-9 protein was also increased by different concentrations of EGF (0,1, 10, 20 ng/ml) in JEG-3 cells after 24 h-culture. The abundance of MMP-9 protein in the three groups was 0. 043 ±0. 012, 0. 085 ±0. 008, 0. 142 ±0. 015, with a significantly higher expression, compared with 0 ng/ml of EGF treatment (0. 004 ±0.001, P < 0.05) respectively. Similarly, MMP-9 proteins were also increased with the increasing incubation time. Compared to EGF(10 ng/ml) stimulation for 0 h (0. 030 ±0. 009) , the profiles of MMP-9 protein were 0. 137 ± 0. 010, 0. 240 ± 0. 010, 1.240 ±0.061 for 4, 12 and 24 hours, respectively (P < 0.05). (3) Both p38MAPK and ERK signalling pathways were activated by EGF in JEG-3 cells. The expression of p-p38MAPK was significantly higher (without or with 10 ng/ml EGF, 234. 1 ± 4. 1 vs.260. 9 ± 2. 5 , P < 0. 05) , however, the p38 MAPK inhibitor SB203580 markedly suppressed the increase in p-p38MAPK content induced by EGF(227. 9 ±2. 4 vs. 260. 9 ±2. 5, P<0. 05). Similarly, the expression of p-ERK was significantly higher with EGF treatment (812. 2 ±3. 5) vs. without EGF group (453.4±5.8) (P <0. 05) , while the ERK inhibitor U0126 significantly inhibited the increased p-ERK content in response to EGF treatment (71. 0 ± 1. 2 vs. 812. 2 ± 3. 5, P < 0. 05) . (4) The p38MAPK inhibitor SB203580 significantly reduced the expression of EGF-induced MMP-9 (0. 645 ± 0. 270 vs. 1. 476 ± 0. 452, P < 0. 05)and NF-kB (0.530 ± 0.026 vs. 0.959 ± 0. 017, P < 0. 05) . (5) The ERK inhibitor U0126 also significantly reduced the expression of EGF-induced MMP-9 (0. 623 ±0. 030 vs. 2. 112 ±0. 056, P <0. 05)and NF-kB (0. 325 ± 0. 082 vs. 0. 939 ± 0. 153, P < 0. 05). Conclusion EGF induced the expression of MMP-9 in a time and dose-dependant manner in JEG-3 cells. EGF enhanced MMP-9 expression through the activation of p38MAPK and ERK signalling pathways in JEG-3 cells.

Objective To investigate the clinical and pathological characteristics of patients with chronic hepatitis B virus(HBV)infection in immune tolerant phase.Methods Ninety-eight chronic HBV carriers in immune tolerant phase were enrolled in this study.The age,gender,serum HBV DNA level,hepatic inflammatory activity and fibrosis,hepatic HBsAg and HBcAg expressions were analyzed.The grade of inflammatory activity and stage of fibrosis were also compared in patients with different levels of serum alanine aminotransferase(ALT).Data analysis was done by chi-square test. Results In 98 patients,83(84.7%)were＜30 years old and 15(15.3%)were≥30.Patients whose mother was HBsAg positive were 48.0%.High levels of serum HBV DNA were found in all patients, with 78.5% were＞1×107 copy/mL.Only 5 cases(5.1%)were G0 of the inflammatory grade;whereas,64 cases(65.3%)were G1,29(29.6%)were G2.There were 56 patients(57.1%)had no significant liver fibrosis;and 23 cases(23.5%)were S1,14(14.3%)were S2,5(5.1%)were S3;none of patients had cirrhosis.The HBsAg and HBcAg in liver tissues were positive in 79(80.6%)and 80(81.6%)cases,respectively.The fibrosis stages of patients with higher ALT levels were significantly greater than patients with lower ALT levels(X2=8.112 3,P=0.043 7).Conclusions Most of patients with chronic HBV infection in immune tolerant phase present mild inflammation in liver,some of them have already developed fibrosis.Therefore,liver pathology is recommended for these patients to help understand the patients' conditions and make correct therapeutic decisions.