Forecasting Medium Term Mortality in Alcohol-related Acute on Chronic Liver Failure (ACLF): A Study from A Tertiary Care Center.

BACKGROUND AND AIM: The first 15 days following the onset of alcoholic acute-on-chronic liver failure (ACLF) represent a critical window, accounting for approximately 80% of the 28-day mortality. This period is pivotal for prognostication and assessing liver transplantation feasibility. However, limited studies have specifically focused on this early phase. The present study aims to comprehensively evaluate clinical outcomes and predictors of mortality within this crucial 15-day period.

METHODS

Clinical and biochemical parameters of 227 alcoholic ACLF patients were collected. Patients were followed up for 90 days or until death, with observations at 0, 4, 7, 15, 30, 45, 60, and 90 days. Statistical analysis focused on 15-day mortality.

RESULTS

Of 227 patients, 41% (94) died within 15 days. Significant differences in baseline parameters were found between those who survived and those who died within 15 days: alcohol intake (198 g/day vs. 144 g/day), serum creatinine (2.2 mg/dl vs. 1.6 mg/dl), lactate (2.8 mmol/l vs. 1.8 mmol/l), and the AARC (APASL ACLF Research Consortium) score (10.7 vs. 9.4). Multivariate Cox regression showed significant hazard ratios (HRs) for creatinine (>1.5 mg/dl, HR 0.44), international normalized ratio (>1.8, HR: 0.47), lactate (>1.8 mmol/L, HR 0.42), and neutrophil counts (>80%, HR 0.43). Patients with alcohol intake <200 g/day had significantly lower mortality (HR: 0.28, P < 0.01) compared to those with >300 g/day. Key prognostic scores included the AARC score (≤7 vs. >10, HR: 0.10) and systemic inflammatory response syndrome (SIRS) (present vs. absent, HR: 9.5). Decision tree analysis showed that the presence of SIRS alone led to 65% mortality, increasing to 100% with alcohol intake >200 g/day and lactate >1.4 mmol/L.

CONCLUSION

Alcoholic ACLF carries high early mortality, with 41% of deaths occurring within 15 days. The presence of SIRS, lactate >1.4 mmol/L, and alcohol intake >200 g/day was associated with high mortality, highlighting a critical window for intervention. Early identification of high-risk patients using this triad can guide timely escalation of care, including transplant referral.