{
  "abstract": "Background Acute-on-chronic liver failure (ACLF) carries high mortality, yet racial and socioeconomic disparities in outcomes remain understudied.Methods We conducted a retrospective cohort study using the National Inpatient Sample (2019-2022), identifying adults with chronic liver disease who developed ACLF (≥2 organ failures). Race/ethnicity (Non-Hispanic White [reference], Non-Hispanic Black, Hispanic, Asian/Pacific Islander, Native American) and insurance status (Medicare, Medicaid, private, uninsured) were primary exposures. The outcome was in-hospital mortality. Sequential multivariable logistic regression models adjusted for demographics, clinical factors (ACLF grade, sepsis, ascites), hospital characteristics, and socioeconomic factors. Cluster-robust standard errors accounted for hospital-level clustering. Effect modification by ACLF grade (Grade 2: 2 organ failures; Grade 3: ≥3) was assessed using interaction terms and stratified analyses. Mediation analysis quantified hospital characteristics’ contribution to disparities.Results Among 366,171 ACLF hospitalizations (1.83 million weighted), overall mortality was 26.7% (Grade 2: 9.5%; Grade 3: 43.4%). The cohort was 66.0% Non-Hispanic White, 14.8% Hispanic, 14.6% Non-Hispanic Black, and 62.4% male (mean age 58.7 years).In fully adjusted models, Non-Hispanic Black patients had 18% higher mortality versus Non-Hispanic White patients (aOR 1.18, 95% CI 1.15-1.21, p<0.001). Asian/Pacific Islander patients also experienced elevated mortality (aOR 1.13, 95% CI 1.08-1.18). Uninsured patients had 47% higher mortality compared to Medicare (aOR 1.47, 95% CI 1.41-1.54, p<0.001).Significant effect modification by ACLF severity was observed (p-interaction <0.001). Among Grade 2 ACLF patients, Non-Hispanic Black patients showed no disparity (aOR 0.96, 95% CI 0.92-1.01). However, among Grade 3 ACLF patients, Non-Hispanic Black patients had 26% higher mortality (aOR 1.26, 95% CI 1.23-1.30). Similarly, the uninsured disparity was more pronounced in Grade 3 (aOR 1.50) versus Grade 2 (aOR 1.38) (IDDF2026-ABS-0240 Tables 1, IDDF2026-ABS-0240 Table 2)Mediation analysis revealed hospital characteristics explained only 7.3% of the Black-White disparity, indicating within-hospital care differences rather than differential access to high-quality institutions. The Black-White disparity remained stable across the COVID-19 pandemic years (2019-2022), while Hispanic patients experienced disproportionate mortality increases during 2020-2021.Conclusions The racial ACLF mortality disparity emerges specifically in severe disease (Grade 3), suggesting inequities in critical care interventions. Minimal mediation by hospital factors indicates that within-hospital care processes, not access, drive these disparities, highlighting the need for equitable critical care delivery initiatives.Abstract IDDF2026-ABS-0240 Table 1Baseline characteristics of ACLF cohort by race/ethnicityCharacteristicOverall (N=366,171)NH-White (n=241,624)NH-Black (n=53,571)Hispanic (n=54,256)Asian/PI (n=11,162)Native Am. (n=5,558)Age, mean (SD)58.7 (13.2)60.1 (12.8)55.2 (12.9)55.4 (13.7)59.8 (14.1)52.1 (12.4)Male, %62.464.157.863.259.556.7Insurance, %Medicare52.155.250.742.352.830.9Medicaid22.118.332.127.820.453.4Private21.322.614.222.723.811.8Uninsured4.53.93.07.23.03.9ACLF Grade, %Grade 249.249.446.751.144.849.5Grade 350.850.653.348.955.250.2Organ failures, mean2.852.842.932.802.972.83Hospital type, %Urban teaching78.776.385.780.284.171.2Mortality, %26.726.429.424.930.524.5Abbreviations: ACLF, acute-on-chronic liver failure; NH, Non-Hispanic; PI, Pacific Islander; SD, standard deviationAbstract IDDF2026-ABS-0240 Table 2In-Hospital mortality by race/ethnicity and insurance status, stratified by ACLF gradeGroupOverallGrade 2Grade 3Overall26.7%9.5%43.3%Race/EthnicityNH-White26.4%9.6%42.6%NH-Black29.4%8.7%47.4%Hispanic24.9%8.1%42.3%Asian/PI30.5%10.2%47.0%Native American24.5%8.3%40.6%",
  "authors": [
    {
      "affiliations": [
        "New York Medical College, United States"
      ],
      "name": "Jeril Lasington"
    },
    {
      "affiliations": [
        "Rutgers University, United States"
      ],
      "name": "Lawin Steve Mathew Lasington"
    },
    {
      "affiliations": [
        "Boston University, United States"
      ],
      "name": "Swamynathan Umamaheshwaran"
    },
    {
      "affiliations": [
        "New York Medical College, United States"
      ],
      "name": "Harika Manohar"
    }
  ],
  "title": "IDDF2026-ABS-0240 Equal until critical: racial disparities in ACLF mortality",
  "uid": "d7f896f0-f478-5597-b6e9-62c4815057cf"
}