From rescue to recovery: Reframing severe alcoholic hepatitis management through 90-day survival

Severe alcoholic hepatitis remains one of hepatology's most urgent challenges, with rapid clinical deterioration and high early mortality. This manuscript comments on and contextualizes the recent systematic review by Quiñones-Calvo et al, which redirects attention from short-term endpoints toward 90-day survival, integrating evidence from associated clinical studies. For decades, corticosteroids have been the mainstay of treatment, reducing 28-day mortality but offering limited benefit for three months. The review emphasizes that the most critical threats to recovery, late infections, renal decline, and relapse, often emerge after the first month. By synthesizing recent studies, it highlights promising interventions such as fecal microbiota transplantation (FMT), which improved 90-day survival in a small randomized trial, and granulocyte colony-stimulating factor (G-CSF), which showed a robust survival benefit in a large retrospective cohort, alongside emerging strategies like plasma exchange and targeted biologics. These findings support a shift toward a two-phase care model: Early stabilization followed by recovery consolidation. For clinicians, such a model may help guide treatment decisions, with therapies like FMT or G-CSF warranting consideration in corticosteroid non-responders, pending further validation in larger randomized controlled trials. Adoption of 90-day survival as a central metric could bridge the gap between initial rescue and sustained remission, providing a more realistic measure of therapeutic success in one of hepatology's most unforgiving conditions.