Clinical value and safety of liver biopsy in patients with liver failure

BACKGROUND: To evaluate the safety, etiological diagnostic value, and impact on clinical treatment decisions of transjugular liver biopsy (TJLB) and percutaneous liver biopsy (PLB) in patients with liver failure. METHODS: This retrospective study included patients with liver failure who underwent liver biopsy between January 1, 2017, and November 30, 2025. Demographic characteristics, clinical data, post-procedural adverse events, and pathological diagnoses were collected and subjected to statistical analysis. RESULTS: A total of 53 patients with liver failure were included, comprising 40 patients with acute-on-chronic liver failure (ACLF) and 13 patients with acute or subacute liver failure. 13 patients received TJLB, all of whom had ACLF. Compared with the PLB, patients in the TJLB group had a higher international normalized ratio (INR) [1.61 (1.32, 1.98)], a lower platelet count (PLT) [89.00 (73.00, 129.00) × 10⁹/L], and were more frequently complicated by moderate to large ascites. Both PLB and TJLB were successfully performed, with a low overall complication rate and no serious adverse events. Even among patients with marked coagulation abnormalities or concomitant ascites, TJLB demonstrated acceptable safety. Histopathological examination following liver biopsy enables reclassification of both chronic liver disease etiologies and acute precipitating factors in patients with ACLF, as well as etiological diagnoses in patients with acute liver failure (ALF) or subacute liver failure (SALF). A substantial proportion of drug- or toxin-related acute liver injury was identified by histopathological examination (n = 32, 60%), leading to a decreased proportion of liver failure with unclear etiology. Based on the pathological diagnosis, treatment strategies were modified in 11% of patients, including the initiation or continuation of specific therapeutic regimens. CONCLUSIONS: In patients with liver failure, liver biopsy provides crucial information for determining the etiology and guiding clinical decision-making. With appropriate selection of the biopsy approach and patient population, TJLB can serve as a safe and feasible option, particularly for patients with coagulation disorders or severe ascites.