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. HOW TO CITE THIS ARTICLE: Saravanamuthu PK, Das AK, Rajkakati R, Sonowal A. 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. Indian J Crit Care Med 2026;30(8):650-655.