S2925 Trends and Predictors of In-Hospital Mortality in Acute-on-Chronic Liver Failure: A Nationwide Analysis

Introduction: Acute-on-chronic liver failure (ACLF) is a serious complication of chronic liver disease, characterized by acute decompensation and multi-organ failure. Despite its rising prevalence in recent years, recent data on hospitalization outcomes for ACLF remain limited. Methods: Using the Nationwide Inpatient Sample (2016–2020), we identified hospitalized patients aged ≥18 years with ACLF based on the North American Consortium for the Study of End-Stage Liver Disease criteria, defined as cirrhosis with ≥2 organ failures (respiratory failure requiring mechanical ventilation, shock, grade ≥3 hepatic encephalopathy, or renal failure requiring dialysis or replacement therapy). Our primary outcome was in-hospital mortality (IHM). We used the Cochrane-Armitage test to assess overall and etiology-specific trends in IHM. Additionally, survey-weighted multivariable logistic regression was conducted to identify predictors of IHM, including etiology, demographic characteristics, and comorbidity burden (Charlson Comorbidity Index [CCI]), with hospital characteristics included as covariates. Results: We analyzed a total of 32,311 ACLF adult hospitalizations, with mean age 58 (SD, ± 12) years, 61% man and 62% non-Hispanic White, 43% Medicare beneficiaries, and 52% having alcoholic liver disease (ALD) as the underlying etiology. The overall IHM rate was 50.3%. Although ACLF related to viral hepatitis had the highest IHM (51.6%), the differences in mortality across etiologies were not statistically significant. The overall IHM rate increased significantly from 2016 to 2020, with the most notable rise occurring between 2019-2020 (48.2% to 51.6%). A similar trend was observed in ALD (47.7% to 50%, P < 0.05). Notably, the greatest increase in IHM occurred among patients with ACLF due to other etiologies (50.7% in 2016 to 55.2% in 2020; P < .001). After multivariable adjustment, ALD (OR 1.61 [95% CI: 1.56–1.67]), other etiologies (OR 1.23[1.18–1.13]), CCI 4–6 (OR 1.35[1.30–1.39]), CCI ≥7 (OR 1.75[1.69–1.81]), AA race (OR 1.07[1.03–1.11]), and no insurance (OR 1.16[1.09–1.22]) were significantly associated with increased odds of IHM among ACLF admissions. Conclusion: We report a rising trend in IHM among ACLF admissions in the US, particularly in ALD and ACLF due to other etiologies. Additionally, AA race, lack of insurance, ALD, other etiologies, and a high comorbidity burden were associated with higher odds of IHM, underscoring the urgent need to address these disparities.