Failure to rescue in acute liver failure: A multicenter cohort study.

Summary

In a 665-patient multicenter cohort of acute liver failure, failure-to-rescue (death within 21 days among those with day-1 complications) was 32.8% overall, with ARDS carrying a 48.1% rate. Each additional day-1 complication increased transplant-free 21-day mortality by 38%, underscoring early identification and management of complications.

Key Findings

• Overall failure-to-rescue rate across 12 medical complications was 32.8% in ALF.
• ARDS had a 48.1% failure-to-rescue rate; GI bleed 63.6%, non-GI bleed 53.9%, vasopressor requirement 52.5%.
• Per each added day-1 complication, 21-day transplant-free mortality odds increased by 38% (aOR 1.38 [1.24–1.54]; c-statistic 0.77).
• 69.3% had at least one day-1 complication; median number 1 [IQR 0–3].

Clinical Implications

For ALF patients, ARDS and bleeding events are high failure-to-rescue complications; prioritize prevention, rapid detection, and aggressive early management, and incorporate complication burden into risk stratification and resource allocation.

Limitations

• Retrospective analysis subject to residual confounding and misclassification
• Findings are specific to ALF and may not generalize to other medical populations

Future Directions

Integrate failure-to-rescue metrics into prospective quality improvement programs; test targeted bundles for early detection and management of ARDS and bleeding in ALF; validate in external cohorts.