Dynamic Changes in C-reactive Protein and Procalcitonin as Predictors of 28-day Mortality in Acute-on-chronic Liver Failure: A Prospective Observational Study from Northeast India

Background and aims: Acute-on-chronic liver failure (ACLF) carries a 28-day mortality of 30-55%, driven largely by systemic inflammation that is not captured by model for end-stage liver disease-sodium (MELD-Na) or chronic liver failure consortium ACLF (CLIF-C ACLF) scores.We evaluated whether serial measurements of C-reactive protein (CRP) and procalcitonin (PCT), and their 48-to 72-hour dynamic changes, predict 28-day mortality in critically ill ACLF patients. Patients and methods: Prospective observational study of 70 consecutive ACLF patients [European Association for the Study of the Liver-Chronic Liver Failure (EASL-CLIF) criteria] at a tertiary intensive care unit (ICU) in Northeast India (October 2024-September 2025).C-reactive protein and PCT were measured at day 1 and day 3 (48-72 hours); ΔCRP and ΔPCT were calculated and analyzed against ACLF grade, severity scores, and 28-day outcome.Receiver operating characteristic (ROC) analysis with DeLong 95% confidence intervals (CIs) and multivariable logistic regression were performed.Results: Mean age was 42.2 ± 9.6 years; 88.6% were male; alcohol-related liver disease accounted for 68.6%; grade III ACLF was present in 48.6%.Overall 28-day mortality was 55.7% (82.4% in grade III).Day 3 values and dynamic changes were more discriminative than baseline values.For 28-day mortality, ΔCRP achieved an area under the curve (AUC) of 0.845 (95% CI 0.741-0.950)and ΔPCT 0.810 (95% CI 0.699-0.920),both substantially exceeding admission CRP (0.712, 95% CI 0.587-0.837),admission PCT (0.671, 95% CI 0.541-0.800),MELD-Na (0.611, 95% CI 0.474-0.748),and CLIF-C ACLF (0.637, 95% CI 0.506-0.767).On multivariable logistic regression, ΔCRP [odds ratio (OR) 2.19, 95% CI 1.15-4.16;p = 0.017] and grade III ACLF (OR 11.36, 95% CI 2.66-48.46;p = 0.001) were independently associated with 28-day mortality.Conclusions: Dynamic 48-to 72-hour changes in CRP and PCT outperform single admission values and conventional scores in predicting 28-day mortality in ACLF, providing a practical, low-cost prognostic adjunct for the ICU.