Secondary Hepatic Dysfunction in Critically Ill Children: Prognostic Associations Beyond PRISM III and PELOD-2 Scores

<b>Background:</b> Secondary hepatic dysfunction is a frequent yet often under-recognized complication in critically ill children. It commonly arises as a consequence of systemic processes-particularly sepsis, hypoperfusion, hypoxia, and multiorgan dysfunction-rather than primary hepatobiliary disease. This study aimed to determine the incidence, clinical characteristics, and prognostic significance of secondary hepatic dysfunction in a pediatric intensive care unit (PICU) cohort, and to evaluate its relationship with PRISM III and PELOD-2 scores. <b>Methods:</b> This retrospective study included patients hospitalized in a tertiary PICU between January 2022 and December 2024. Children with pre-existing liver disease or primary acute liver failure were excluded. Hepatic dysfunction was defined by elevations in age-adjusted biochemical markers. Demographic variables, clinical interventions, laboratory values, and outcomes were recorded. Mortality risk and prolonged PICU stay (>7 days) were analyzed in relation to hepatic dysfunction, PRISM III, and PELOD-2 scores. <b>Results:</b> Among 567 PICU admissions, 50 patients (8.8%) met criteria for secondary hepatic dysfunction. The cohort had a median age of 57.5 months and 66% were male. Hepatocellular injury predominated (96%), while cholestatic patterns were less common (4%). Overall mortality was 22%. Mortality was significantly associated with sepsis (<i>p</i> = 0.04), mechanical ventilation (<i>p</i> < 0.01), and inotropic support (<i>p</i> < 0.01). Both PRISM III and PELOD-2 scores were higher in non-survivors on day 1 and day 7 (<i>p</i> ≤ 0.01). ALT ≥ 2 × ULN and total bilirubin > 2 mg/dL were not independently predictive of mortality. <b>Conclusions:</b> Secondary hepatic dysfunction is relatively common in critically ill children and is associated with adverse clinical outcomes. Its prognostic relevance appears to extend beyond conventional severity scores, particularly with respect to morbidity-related outcomes such as prolonged PICU stay, suggesting that routine hepatic assessment may contribute to early risk stratification in the PICU setting.