S2664 ACLF Grade Evolution as a Predictor of Short-Term Outcomes in a Liver ICU

Introduction: Patients with acute-on-chronic liver failure (ACLF) in the Intensive Care Unit (ICU) experience high rates of short-term mortality and require increased healthcare resource utilization. Understanding that ACLF is a dynamic syndrome, serial assessment of ACLF grades in critically ill patients is necessary to inform prognostication and liver transplant candidacy decision-making. Methods: Patients admitted to a quaternary care center Liver ICU between August 2018 and August 2023 were enrolled into a prospective patient registry; 491 patients (614 ICU admissions) had ACLF defined by EASL-CLIF criteria. ACLF grade was assessed on ICU days (D) 1, 3 and 7; MELD-Na scores were assessed on D1 and 7. Patients were stratified by transplant-free survival (TFS) at 28 days. ACLF grade changes were classified as “resolved,” “improving”, “stable”, or “progressing.” Survival at 28 days was compared by grade trajectories using chi-square (survival status and ACLF trajectory) and Welch’s t-test (MELD-Na). Results: ACLF-3 was present on D1 in a higher proportion of 28-day non-survivors than survivors (25.8% [50/194] vs 54.4% [174/320], P < 0.001). Improvement in ACLF grade from D1 to D3 was significantly more likely to occur in survivors (35.6% vs 10.3%, P < 0.001). By D7, survivors were more likely to improve to ACLF grade 0 or 1 than non-survivors (46.9% vs 18.1%, P < 0.001). Among those with ACLF-3 at D1, a higher proportion of survivors improved to grade 2 or 1 by D3 (47.5% vs 26.7%, P = 0.008). MELD-Na was lower in survivors at D1 (29.24 vs 32.73, P < 0.001) and D7 (30.9 vs 35.55, P < 0.001). Conclusion: Early improvement in ACLF grade within the first week of ICU admission is associated with improved 28-day TFS. Dynamic changes in ACLF grade and MELD-Na offer important prognostic value and may support liver transplant candidacy assessment in critically ill patients. Optimal management requires a multidisciplinary approach, with collaboration between hepatology, critical care, transplant, nephrology, and other specialist teams to implement timely organ-specific interventions and guide decision-making.