Hepatic Encephalopathy Severity and Mortality Risk Stratification in Alcohol-Related Acute-on-Chronic Liver Failure

Background/Objectives: Acute-on-chronic liver failure (ACLF) is characterized by multiple organ failure and short-term mortality, and hepatic encephalopathy (HE) is its frequent complication. We investigated whether the severity of HE upon admission in patients with alcohol-related ACLF at the intensive care unit (ICU) was associated with short-term mortality. Methods: In total, 100 patients with alcohol-related ACLF and HE admitted in ICU were enrolled in the study. Laboratory biomarkers, total hospital length of stay (LOS), ICU length of stay, acute kidney injury (AKI), Acute Physiology and Chronic Health Evaluation II score, CLIF-C organ failure and Sequential Organ Failure Assessment score were tested in relation to the mortality risk. HE was assessed and divided into groups using the West Haven criteria. Results: Total hospital LOS, 7-day and 28-day mortality were significantly higher in the higher-grade HE group (p = 0.035, p = 0.031, p = 0.002, respectively). CLIF-C OF, SOFA, and APACHE II scores were significantly higher in the higher-grade HE group (p < 0.001). Kaplan-Meier survival analysis demonstrated reduced survival in patients with higher-grade HE (log-rank p < 0.001). In Cox regression analyses, AKI was associated with short-term mortality in both HE groups. Total hospital LOS and ICU length of stay were also associated with mortality, but were interpreted as post-baseline markers of clinical trajectory rather than baseline prognostic predictors. Conclusions: In patients with alcohol-related ACLF and HE, higher-grade HE was associated with poorer short-term survival. AKI and higher CLIF-C OF, SOFA and APACHE II scores were associated with poor outcomes, supporting their clinical relevance for mortality risk stratification in this population. LOS-related findings should be interpreted as markers of clinical trajectory rather than baseline prognostic predictors.