Hernaez R, et al. - In a large cohort of patients with acute-on-chronic liver failure (ACLF) in the US, researchers analyzed the prevalence and risk factors correlated with the development and short term mortality. Patients with ACLF were identified during hospitalisation for decompensated cirrhosis at any of the 127 VA hospitals between January 1, 2004, and December 31, 2014, using the US Department of Veterans Affairs (VA) Corporate Data Warehouse. They examined ACLF prevalence and variables associated with 28- and 90-day mortality in ACLF, as well as trends in prevalence and survival over time. Findings suggested an association of older age, White race, liver cancer, higher model for end-stage liver disease sodium corrected score, and non-liver transplant centre with an increased risk of death in ACLF. Overall, the investigators suggested that ACLF was common and linked to high short-term mortality in a US cohort of hospitalised patients with decompensated cirrhosis. ACLF prevalence has decreased over a decade, but ACLF-3 survival improvement has not been seen. Early recognition and aggressive management may lead to improved outcomes in ACLF, including timely referral to transplant centres.