The 90‐Day Survival Threshold: A Pivotal Determinant of Long‐Term Prognosis in HBV‐ACLF Patients – Insights from a Prospective Longitudinal Cohort Study

Abstract This work aims to explore the long‐term prognosis of hepatitis B virus‐related acute‐on‐chronic liver failure (HBV‐ACLF). In this prospective study, eligible inpatients with HBV‐ACLF are enrolled and followed up from December 2012 to February 2023, for clinical events, laboratory tests at least every 6 months. Overall, the survival rates at 28 days, 90 days, 1 year, 5 years, and 8 years are 64.7%, 48.8%, 46.1%, 43.8%, and 42.2%, respectively. Among the 8‐year mortality and liver transplant cases, ACLF survivors (who survived over 90 days) accounted for 7.8% (9/115). Among 101 patients who survived for more than 90 days, 97.9% of patients achieve virologic response at 1 year. For HBeAg‐positive patients, the HBeAg seroconversion are 25.5%, 63.6%, and 76.9% at 1, 5, and 8 years, respectively. Alanine aminotransferase, aspartate aminotransferase, total bilirubin, INR, white blood cell count, and albumin levels gradually improve within the first year. Fibrosis biomarkers APRI, FIB‐4 and Chitinase‐3‐like protein 1 (CHI3L1) levels decreases within the first 5 years. The Cox proportional hazards regression reveal that high total bilirubin (HR = 1.008, p = 0.021) is the independent risk factor for 8‐year survival of ALCF survivors. The 90‐day period following of HBV‐ACLF represented a critical juncture for long‐term prognosis, revealing favorable outcomes beyond this timeframe.