Etiology, clinical features, and outcomes in acute-on-chronic liver failure patients in the intensive care unit of a quaternary care center

Background: Multi-organ failure and a sharp decline in liver function are hallmarks of acute-on-chronic liver failure (ACLF), carrying high mortality. Objective: To determine the etiology, clinical presentations, and the mortality outcome in patients with acute-on-chronic liver disease. Methods: In this retrospective study, medical records of 109 patients admitted to the Intensive Care Unit (ICU) of Pakistan Kidney and Liver Institute and Research Center, Lahore, Pakistan, from 1st January 2022 to 31st August 2023 with ACLF were included after ethical approval (PKLI-IRB/AP/149). Data regarding demographics, clinical features, comorbidities, Child-Turcotte-Pugh (CTP) score, Chronic Liver Failure Consortium (CLIF-C score), Model for End-stage Liver Disease-Na (MELD-Na), and ACLF grades were recorded, and their outcome in terms of mortality was noted. Results: The mean age was 47.4 ± 10.5. The primary cause of cirrhosis was hepatitis C virus (HCV) infection (52.3%), followed by cryptogenic cirrhosis (14.7%). According to the CTP score, 95.4% of the patients had Child-Pugh class C cirrhosis, and 52.3% were classified as grade 3 ACLF. Out of 109 patients, only 31 survived, with a mortality rate of 71.6%. Acute decompensation was mainly secondary to hepatic encephalopathy precipitated by infections and variceal bleeding. The non-survivors had significantly higher INR=3.4 ± 1.8 vs 2.6 ± 1.1 (p=0.002) and ammonia levels =230.1 ± 241.7 µg/dL vs 125.7 ± 65.7 µg/dL (p=0.002) on ICU admission compared to those who survived. The mean MELD-Na score at hospital admission was 32.9 ± 6.5, and in ICU admission was 34.7 ± 6.7 (p<0.001), but was not significant regarding survival (p=0.195). The CLIF-C score increased from 50.4±10.1 (in ward) to 56.1 ±10.2 (ICU transfer) (p<0.001) and was also higher in non-survivors compared to survivors (p<0.001). It is observed that increasing CLIF-C scores is a sign of poor prognosis. Conclusion: HCV infection was the most common cause of cirrhosis, and hepatic encephalopathy was the common trigger for ACLF. A high INR, hyperammonia, advanced ACLF grade, and an increase in CLIF-C score lead to poor outcomes in terms of survival, while worsening of CLIF-C scores may additionally predict short-term mortality.