Observational Study
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World J Gastroenterol. Oct 28, 2014; 20(40): 14934-14941
Published online Oct 28, 2014. doi: 10.3748/wjg.v20.i40.14934
Chronic Liver Failure-Sequential Organ Failure Assessment is better than the Asia-Pacific Association for the Study of Liver criteria for defining acute-on-chronic liver failure and predicting outcome
Radha K Dhiman, Swastik Agrawal, Tarana Gupta, Ajay Duseja, Yogesh Chawla
Radha K Dhiman, Swastik Agrawal, Tarana Gupta, Ajay Duseja, Yogesh Chawla, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India
Author contributions: Dhiman RK conceived the idea for the study, performed analyses, interpreted data and prepared the manuscript; Agrawal S and Gupta T were responsible for data collection, analyses, interpreting data, and assisted in preparing the manuscript; Duseja A and Chawla Y assisted the interpretation of the data and in the preparation of the manuscript; all authors were involved in patient care management.
Correspondence to: Radha K Dhiman, MD, DM, FAMS, FACG, Professor, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India. rkpsdhiman@hotmail.com
Telephone: +91-99-14209337 Fax: +91-17-22744401
Received: March 25, 2014
Revised: May 8, 2014
Accepted: June 12, 2014
Published online: October 28, 2014
Abstract

AIM: To compare the utility of the Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) and Asia-Pacific Association for the Study of Liver (APASL) definitions of acute-on-chronic liver failure (ACLF) in predicting short-term prognosis of patients with ACLF.

METHODS: Consecutive patients of cirrhosis with acute decompensation were prospectively included. They were grouped into ACLF and no ACLF groups as per CLIF-SOFA and APASL criteria. Patients were followed up for 3 mo from inclusion or mortality whichever was earlier. Mortality at 28-d and 90-d was compared between no ACLF and ACLF groups as per both criteria. Mortality was also compared between different grades of ACLF as per CLIF-SOFA criteria. Prognostic scores like CLIF-SOFA, Acute Physiology and Chronic Health Evaluation (APACHE)-II, Child-Pugh and Model for End-Stage Liver Disease (MELD) scores were evaluated for their ability to predict 28-d mortality using area under receiver operating curves (AUROC).

RESULTS: Of 50 patients, 38 had ACLF as per CLIF-SOFA and 19 as per APASL criteria. Males (86%) were predominant, alcoholic liver disease (68%) was the most common etiology of cirrhosis, sepsis (66%) was the most common cause of acute decompensation while infection (66%) was the most common precipitant of acute decompensation. The 28-d mortality in no ACLF and ACLF groups was 8.3% and 47.4% (P = 0.018) as per CLIF-SOFA and 39% and 37% (P = 0.895) as per APASL criteria. The 28-d mortality in patients with no ACLF (n = 12), ACLF grade 1 (n = 11), ACLF grade 2 (n = 14) and ACLF grade 3 (n = 13) as per CLIF-SOFA criteria was 8.3%, 18.2%, 42.9% and 76.9% (χ2 for trend, P = 0.002) and 90-d mortality was 16.7%, 27.3%, 78.6% and 100% (χ2 for trend, P < 0.0001) respectively. Patients with prior decompensation had similar 28-d and 90-d mortality (39.3% and 53.6%) as patients without prior decompensation (36.4% and 63.6%) (P = NS). AUROCs for 28-d mortality were 0.795, 0.787, 0.739 and 0.710 for CLIF-SOFA, APACHE-II, Child-Pugh and MELD scores respectively. On multivariate analysis of these scores, CLIF-SOFA was the only significant independent predictor of mortality with an odds ratio 1.538 (95%CI: 1.078-2.194).

CONCLUSION: CLIF-SOFA criteria is better than APASL criteria to classify patients into ACLF based on their prognosis. CLIF-SOFA score is the best predictor of short-term mortality.

Keywords: Cirrhosis, Acute decompensation, Mortality, Prognosis, Acute on chronic liver failure

Core tip: The most common acute precipitant for acute-on-chronic liver failure (ACLF) is infection. The Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) criteria is better than Asia-Pacific Association for the Study of Liver criteria in defining ACLF as the CLIF-SOFA criteria identifies patients with a high likelihood of mortality who could benefit from liver transplantation or inclusion into trials of newer therapeutic modalities. Mortality increases with increasing grades of ACLF based on number of organ failures in Asian-Indian patients similar to the results seen in the European population. Also, the multi-organ failure CLIF-SOFA score is better than liver specific Model for End-Stage Liver Disease and Child-Pugh scores, suggesting that ACLF leads to multi-organ failure and is not limited to the liver.