Dynamic course and outcomes of acute-on-chronic liver failure in the intensive care unit

BACKGROUND: Acute-on-chronic liver failure (ACLF) frequently requires intensive care unit (ICU) management, yet real-world data on dynamic disease course, organ support and mortality predictors in critically ill ACLF patients remain scarce. METHODS: All ACLF patients admitted to a tertiary care hepatology ICU between 2013 and 2023 were analyzed in this retrospective single-center study for ACLF grade trajectories, organ support, and independent predictors of 90-day mortality. RESULTS: Among 209 patients (228 admissions), 54.4% had ACLF grade 3 at ICU admission (median CLIF‑C ACLF 56). Most patients required vasopressors (86.8%), invasive mechanical ventilation (59.6%), and renal replacement therapy (53.5%). The ICU and 90-day survival were 56.1% and 34.2%, respectively. One third of the patients (33.3%) showed improvement in ACLF grade during the ICU stay, including grade 3 patients, indicating meaningful reversibility under comprehensive organ support. The CLIF‑C ACLF score (OR: 1.07, 95% CI: 1.03-1.11, p < 0.001) and the peak noradrenaline dose (OR: 13.5, 95% CI: 3.18-69.7, p < 0.001) were identified as independent predictors of 90-day mortality. CONCLUSION: Critically ill ACLF patients retain potential for partial recovery under full organ support, justifying ICU escalation even in grade 3 disease. Peak noradrenaline dose, alongside the established prognostic scores, provides a readily available parameter to guide individualized decision-making regarding full organ support or timely de-escalation.