*Purpose: Pediatric acute liver failure (PALF) is a potentially devastating illness that affects otherwise healthy children. Nearly 70% of children with PALF will recover, while >25% will require emergent liver transplant (LT). PALF has an estimated overall mortality of 15%. Beyond short term outcomes, the long-term clinical course of PALF has not been established. This study aims to characterize long term outcomes and identify prognostic factors of PALF using registry data.

*Methods: Children (<18 years) admitted with PALF were identified by ICD codes in the California Office of Statewide Health Planning and Development Patient Discharge Dataset (1/2005-12/2018). Multivariable Cox proportional hazards models were used to identify risk factors for liver transplant and death.

*Results: Among 2162 inpatients with PALF, the mean age at presentation was 9.7±6.2 years, with a median follow-up of 4.6 (IQR 0.06 -10.4) years. 50.1% were female and 44.2% Hispanic. Most deaths occurred within 4 months of presentation. Children <2 years (18.2% of patients) were more likely to undergo LT (HR 2.74 [95% CI 1.96-3.83], p<0.001) and more likely to die (HR 1.66 [95% CI 1.33-2.07], p<0.001) when compared to children >10 years old (52.3% of patients) (Table 1). Mortality was higher among females (HR 1.47 [95% CI 1.17-1.85], p<0.001). No statistically significant difference was observed based on race/ethnicity.

*Conclusions: This large, highly diverse population-based study of long-term outcomes following PALF demonstrates that children who present <2 years of age are more likely to die or require emergent LT, highlighting the importance of early referral to a transplant center. Further, this analysis demonstrates higher mortality in females, for unclear reasons. Strategies to improve referral patterns and explore potential sex disparities for patients with PALF are needed.

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