[Impact of key indicator dynamic change on 90-day prognosis for patients with acute-on-chronic liver failure]

Objective: To compare and analyze the impact of key indicator dynamic change on the 90-day prognosis of patients who remain in a state of acute-on-chronic liver failure (ACLF) at 28 days so as to provide new evidence for individualized treatment. Methods: ACLF patients who visited Beijing You'an Hospital, affiliated with Capital Medical University; Tianjin Third Central Hospital; and the Fifth Medical Center of the Chinese PLA General Hospital between January 2015 and December 2023 were prospectively included. Follow-up was conducted until 90 days for patients who remained in an ACLF state at 28 days. The key clinical indicator dynamic changes were compared from baseline to 28 days, including total bilirubin (TBil) and international normalized ratio (INR) for their impact on 90-day prognosis. TBil trends were classified as recovery, improvement, and deterioration. INR trends were classified as improvement and deterioration. Patients of both groups were divided into survival and death (including liver transplantation) according to their 90-day outcomes. Continuous data were compared using independent t-tests or rank-sum tests. Categorical data were compared using χ² tests. Kaplan-Meier survival analysis was used to compare survival curves among different patient groups. Results: A total of 739 cases were included, of which 313 remained in an ACLF state at 28 days, with a 90-day survival rate of 66.1% (207/313), a liver transplantation rate of 5.1% (16/313), and a mortality rate of 28.8% (90/313). The proportion of INR deterioration was 30.9% (64/207) and 90.6% (96/106), and the improvement was 69.1% (143/207) and 9.4% (10/106) in the survival group and the death group (including liver transplantation), respectively. The proportion of TBil deterioration was 31.4% (65/207) and 71.7% (76/106) and the proportion of improvement 68.6% (142/207) and 28.3% (30/106), with statistically significant differences (P < 0.05). Univariate and multivariate Cox analyses indicated that 28-day INR deterioration [8.06 (4.07-15.95)] and TBil deterioration [3.03 (1.04-8.82)] were independent risk factors affecting 90-day mortality. The area under the curve (AUC) was higher in the INR trend than the TBil trend (0.80 vs. 0.71, P < 0.05) for predicting 90-day mortality. Conclusion: INR and TBil deterioration are independent risk factors for 90-day mortality for patients who remain in an ACLF state at 28 days. However, the INR trend has a greater impact on the 90-day prognosis compared to the TBil trend. This finding provides new insights for prognostic assessment of ACLF patients, aiding individualized treatment achievement and guiding clinicians in developing rational diagnostic and therapeutic strategies.