Role of D-Dimer and Disseminated Intravascular Coagulation (DIC) Score as a Prognostic Marker in Acute-on-Chronic Liver Failure Patients

Background: Acute-on-chronic liver failure (ACLF) is a rapidly progressive syndrome characterized by acute hepatic decompensation, extrahepatic organ failure, and substantial short-term mortality. Although the international normalized ratio is incorporated into widely used prognostic models such as the Model for End-Stage Liver Disease (MELD) and the Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), it provides only a limited representation of the complex disturbances in coagulation and fibrinolysis observed in ACLF. Biomarkers reflecting activation of coagulation pathways, including D-dimer and the disseminated intravascular coagulation (DIC) score, may enhance prognostic assessment. This study investigated the utility of D-dimer and the DIC score for predicting 28- and 90-day mortality in patients with ACLF and developed a novel prognostic model integrating these variables. Methods: In this prospective observational study, 120 consecutive patients diagnosed with ACLF according to the Asia-Pacific Association for the Study of the Liver (APASL) criteria were enrolled at a tertiary care center between December 2022 and April 2024. Baseline demographic, clinical and laboratory data, including D-dimer levels, DIC score, and established prognostic indices such as the APASL-ACLF Research Consortium (AARC) score, MELD-Na, Child-Turcotte-Pugh (CTP) score, and CLIF-Organ Failure (OF) score, were recorded at admission. Patients were followed for 28 and 90 days to determine survival outcomes. Independent predictors of mortality were identified using multivariable logistic regression, and these variables were incorporated into a new prognostic scoring model. Results: Higher D-dimer levels were independently associated with increased 90-day mortality (odds ratio (OR), 0.695; 95% confidence interval (CI), 0.497-0.923; p=0.033). The DIC score independently predicted 28-day mortality (OR, 1.510; 95% CI, 1.051-2.177; p=0.026) and showed significant correlations with ACLF severity, the extent of organ failure, and other adverse clinical outcomes. Its prognostic performance was comparable to that of the AARC score and exceeded that of the MELD-Na and CLIF-OF scores. A newly derived composite AARC-DIC score demonstrated the highest predictive performance, with area under the receiver operating characteristic curve values of 0.788 for 28-day mortality and 0.826 for 90-day mortality. Conclusions: Both D-dimer and the DIC score provide important prognostic information in patients with ACLF. Elevated D-dimer was primarily associated with medium-term mortality, whereas the DIC score independently predicted both short- and medium-term outcomes. The novel AARC-DIC score improved mortality prediction compared with conventional prognostic models and may represent a practical tool for early risk stratification in patients with ACLF.