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Recent reports have highlighted increasing incidence of diabetic ketoacidosis (DKA) cases, following COVID-19. 1 2 While diabetes is linked with hepatic complications, its association with paediatric acute liver failure (ALF) remains poorly understood.3 An unusual trend of post-pandemic DKA-associated ALF, has emerged at the UK’s largest paediatric hepatology centre, resulting in intensive care admission and two fatalities.Children admitted with an initial DKA presentation to a single UK paediatric hepatology centre, in ALF, between January 2010-August 2024 were identified - all three presented after 2020. Demographic, clinical and laboratory data was collected.Patients A (16-year-old female, BMI 20 kg/m²), B (11-year-old male, BMI 27 kg/m²), and C (11-year-old male, BMI 31 kg/m²) were identified. All three presented with DKA; A (mild; pH 7.27), B (severe; pH 6.82), and C (severe; pH 6.9), with no prior diagnosis of diabetes. Patient A presented with a peri-anal abscess, while Patients B and C exhibited reduced consciousness, requiring immediate intubation and ventilation. A head CT revealed cerebral oedema in Patient C. The national UK DKA management protocol was followed, and broad-spectrum antibiotics were initiated. On admission, liver and renal function tests were normal. DKA resolved in the following timeframes: A (6 hours), B (48 hours), and C (72 hours). However, on day 4, all three developed ALF, marked by elevated ALT levels (A: 3615U/L, B: 9984U/L, C: 4245U/L; figure 1i), peak INR (A: >15, B: 4.4, C: 3; figure 1ii), metabolic acidosis and hyperlactatemia (peak lactate A: 19.8 mmol/L, B: 23 mmol/L, C: 7.9 mmol/L). Patient A required intubation and ventilation. ALF management protocol was initiated, including N-acetylcysteine. On day 4, Patients B and C developed cardiovascular instability and acute kidney injury, with Patient A following on day 5. Peak creatinine levels were A: 81µmol/L, B: 86µmol/L, and C: 100µmol/L (figure 1iii). All three required escalating inotropic support, haemofiltration, and urgent transfer to the paediatric hepatology centre. Prior to ALF, all patients received therapeutic paracetamol (A: 60 mg/L, B: 24 mg/L, C: 16 mg/L). A hyperinflammatory state was evident in all patients. Microbiology investigations revealed; A - abscess; Escherichia coli, Group B streptococcus; B - nasopharyngeal aspirate; metapneumovirus and C - culture-negative chest infection. Viral, immunology, and metabolic investigations for ALF were negative. All three patients progressed to refractory shock. Cardiac arrest occurred on day 6 for all patients, leading to the deaths of Patients A and B. Liver autopsy in the deceased patients showed centriacinar necrosis and microvesicular steatosis. Patient C survived, with liver function tests normalising by day 64.In the post-pandemic era, our centre has observed a severe hepatic phenotype associated with DKA, mirroring the rising incidence of DKA during this period. Factors such as ischemic hepatitis, medications,4 and sepsis likely exacerbate hepatic vulnerability in patients with pre-existing metabolic susceptibilities.5 The increasing prevalence of obesity may further elevate this risk, contributing to our observation.6 In addition to promoting early recognition of DKA, we urgently recommend incorporating liver function monitoring into UK DKA guidelines to facilitate early detection of liver injury and reduce associated mortality.Abstract OC89 Figure 1Trend in i) alanine aminotransferase (ALT), ii) international normalised ratio (INR) and iii) renal function using creatinine as a maker, across the admission course of Patients A-CReferences Ponmani C, Roland D, Lyttle MD, et al. Characteristics of children presenting with new onset diabetes and DKA in the COVID-19 pandemic: a national cohort study. Front Disaster Emerg Med. 2024 Aug 22;2.Buczkowski K, Ożóg-Zabolska I, Gulczyński J, et al. Hypoxic hepatitis as a complication of newly diagnosed type 1 diabetes in a teenager. Autopsy & Case Reports 2022 Apr 14;12:e2021372.Deep A, Alexander EC, Bulut Y, et al. Advances in medical management of acute liver failure in children: promoting native liver survival. Lancet Child Adolesc Health. 2022 Oct;6(10):725–37.Louvet A, Ntandja Wandji LC, Lemaître E, et al. Acute liver injury with therapeutic doses of acetaminophen: a prospective study. Hepatology 2021 May;73(5):1945–55.Kumar A, Arora A, Choudhury A, et al. Impact of diabetes, drug-induced liver injury, and sepsis on outcomes in metabolic dysfunction associated fatty liver disease-related acute-on-chronic liver failure. Am J Gastroenterol. 2024 Jul 17.Rutherford A, Davern T, Hay JE, et al. Influence of high body mass index on outcome in acute liver failure. Clin Gastroenterol Hepatol. 2006 Dec;4(12):1544–9.