Assessment of scoring systems for acute-on-chronic liver failure at predicting short-term mortality in patients with alcoholic hepatitis

Table 1 Formulas for scores used in alcoholic hepatitis

Scores	Formulas
DF[6]	4.6 × [patient’s prothrombin time-control prothrombin time (s)] + total bilirubin (mg/dL)
ABIC score[8]	(age × 0.1) + [serum bilirubin (mg/dL) × 0.08] + [serum creatinine (mg/dL) × 0.3] + (INR × 0.8)
GAHS[9]	Age, blood urea nitrogen, white blood cell count, serum bilirubin, and INR; each scored 1-3
MELD score[14]	MELD = 3.78 ln[bilirubin (mg/dL)] + 11.20ln(INR)+ 9.57ln[creatinine (mg/dL)] + 6.43
MELD-Na score[17]	MELD + 1.59 (135-Na), with maximum and minimum Na of 135 and 120 mEq/L, respectively
CLIF-SOFA score[5]	0	1	2	3	4
Liver (bilirubin, mg/dL)	< 1.2	≥ 1.2 to < 2.0	≥ 2.0 to < 6.0	≥ 6.0 to < 12.0	≥ 12.0
Renal (creatinine, mg/dL)	< 1.2	≥ 1.2 to < 2.0	≥ 2.0 to < 3.5	≥ 3.5 to < 5.0 or use of RRT	≥ 5.0
CNS (HE grade)	No HE	I	II	III	IV
Coagulation (INR)	< 1.1	≥ 1.1 to < 1.25	≥ 1.25 to < 1.5	≥ 1.5 to < 2.5	≥ 2.5 or platelet ≤ 20 × 109/L
Cardiovascular (hypotension)	MAP ≥ 70	MAP < 70	Dopamine ≤ 5 or dobutamine (any dose)1 or terlipressin	Dopamine > 5 or epi ≤ 0.1 or norepi ≤ 0.11	Dopamine > 15 or epi > 0.1 or norepi > 0.11
Respiration
PaO2/FiO2	> 400	> 300 to ≤ 400	> 200 to ≤ 300	> 100 to ≤ 200	≤ 100
Or SpO2/FiO2	> 512	> 357 to ≤ 512	> 214 to ≤ 357	> 89 to ≤ 214	≤ 89
CLIF-C OF score[15]	1	2	3
Liver (bilirubin, mg/dL)	< 6	≥ 6.0 to < 12.0	≥ 12
Renal (creatinine, mg/dL)	< 2	≥ 2.0 to < 3.5	≥ 3.5 or RRT
CNS (HE grade)	0	1-2	3-4
Coagulation (INR)	< 2.0	≥ 2.0 to < 2.5	≥ 2.5
Cardiovascular (hypotension)	MAP ≥ 70	MAP < 70	Vasopressors
Respiration
PaO2/FiO2	> 300	≤ 300 and > 200	≤ 200
Or SpO2/FiO2	> 357	> 214 and ≤ 357	≤ 214

¹Adrenergic agents administered for at least 1 h (disease are given in μg/kg/min). DF: Discriminant function; ABIC: Age, bilirubin, INR creatinine; GAHS: Glasgow Alcoholic Hepatitis Score; MELD: Model for end-stage liver disease; MELD-Na: Modified MELD including sodium; CLIF-SOFA: Chronic Liver Failure-Sequential Organ Failure Assessment; CLIF-C OF: Chronic Liver Failure Consortium Organ Failure score; INR: International normalized ratio; RRT: Renal replacement therapy; HE: Hepatic encephalopathy; MAP: Mean arterial pressure; PaO₂: Partial pressure of arterial oxygen; FiO₂: Fraction of inspired oxygen; SpO₂: Pulse oximetric saturation.

Table 2 Baseline characteristics of patients

Variable	Total cohort	28-d survivors	28-d nonsurvivors	P value
	(n = 264)	(n = 232)	(n = 32)
Age (yr)	48.8 ± 9.1	48.6 ± 9.2	48.3 ± 8.1	0.865
Men, n (%)	204 (77.3%)	175 (75.4%)	29 (90.6%)	0.070
Presence of cirrhosis, n (%)	240 (90.9%)	208 (89.7%)	32 (100%)	0.092
SIRS, n (%)	76 (28.8%)	63 (27.2%)	13 (40.6%)	0.144
Mean blood pressure (mmHg)	89.3 ± 15.9	90.1 ± 15.1	83.5 ± 20.0	0.082
WBC count (× 109/L)	9.6 ± 6.0	9.2 ± 5.9	12.0 ± 6.7	0.013
Platelet count (× 109/L)	109.2 ± 71.5	110.6 ± 72.0	98.7 ± 68.0	0.377
Albumin (g/dL)	2.7 ± 0.6	2.7 ± 0.5	2.3 ± 0.6	< 0.0001
Bilirubin (mg/dL)	11.3 ± 8.6	10.3 ± 8.0	18.7 ± 9.7	< 0.0001
AST (U/L)	157.7 ± 86.6	160.5 ± 88.4	137.3 ± 70.7	0.098
ALT (U/L)	49.9 ± 32.4	50.4 ± 33.3	46.4 ± 24.6	0.514
GGT (U/L)	428.4 ± 437.5	455.4 ± 448.4	236.9 ± 290.5	0.001
Prothrombin time (s)	18.0 ± 5.2	17.3 ± 3.9	22.8 ± 9.6	0.004
INR	1.7 ± 0.6	1.6 ± 0.4	2.3 ± 0.9	0.001
Creatinine (mg/dL)	1.2 ± 1.5	0.9 ± 0.7	2.9 ± 3.6	0.005
Sodium (mEq/L)	133.5 ± 6.6	133.8 ± 6.3	131.1 ± 8.2	0.078
DF score	38.8 ± 28.2	34.9 ± 21.6	68.4 ± 48.0	0.001
ABIC score	7.5 ± 1.4	7.3 ± 1.1	9.0 ± 1.9	< 0.0001
GAHS	7.4 ± 1.5	7.2 ± 1.3	9.1 ± 1.6	< 0.0001
MELD score	21.6 ± 6.9	20.3 ± 5.5	30.6 ± 9.1	< 0.0001
MELD-Na score	24.3 ± 6.8	23.1 ± 5.9	32.3 ± 7.2	< 0.0001
CLIF-SOFA score	6.8 ± 3.1	6.1 ± 2.1	11.5 ± 4.6	< 0.0001
CLIF-C OF score	7.9 ± 2.0	7.4 ± 1.4	11.2 ± 2.9	< 0.0001

Data are presented as mean ± SD or n (%). SIRS: Systemic inflammatory response syndrome; WBC: White blood cell; AST: Aspartate aminotransferase; ALT: Alanine aminotransferase; GGT: Gamma-glutamyltransferase; INR: International normalized ratio; DF: Discriminant function; ABIC: Age, bilirubin, INR, creatinine; GAHS: Glasgow Alcoholic Hepatitis Score; MELD: Model for end-stage liver disease; MELD-Na: Modified MELD including sodium; CLIF-SOFA: Chronic Liver Failure-Sequential Organ Failure Assessment; CLIF-C OF: Chronic Liver Failure Consortium Organ Failure.

Table 3 Performance characteristics of various scoring systems in predicting 28- and 90-d mortality

Scores	AUROC (95%CI)	Cutoff	Sensitivity	Specificity	PPV	NPV
28-d mortality
CLIF-SOFA	0.86 (0.81-0.90)	8	78.1%	79.7%	34.7%	96.4%
CLIF-C OF	0.89 (0.84-0.92)	10	68.8%	91.4%	52.4%	95.5%
DF	0.79 (0.74-0.84)	32	81.3%	50.9%	18.6%	95.2%
ABIC	0.78 (0.72-0.83)	9	43.7%	93.5%	48.3%	92.3%
GAHS	0.81 (0.76-0.86)	9	65.6%	83.2%	35.0%	94.6%
MELD	0.83 (0.78-0.88)	21	87.5%	57.8%	22.2%	97.1%
MELD-Na	0.83 (0.78-0.88)	28	68.8%	80.2%	32.4%	94.9%
90-d mortality
CLIF-SOFA	0.81 (0.76-0.86)	8	66.7%	84.3%	54.8%	89.8%
CLIF-C OF	0.83 (0.78-0.88)	10	52.9%	94.4%	73.0%	87.5%
DF	0.77 (0.71-0.82)	32	78.4%	53.4%	32.5%	89.6%
ABIC	0.78 (0.72-0.83)	9	39.2%	96.1%	74.1%	84.7%
GAHS	0.82 (0.77-0.87)	9	68.6%	88.8%	63.6%	90.8%
MELD	0.81 (0.77-0.87)	21	82.4%	61.8%	38.2%	92.4%
MELD-Na	0.87 (0.82-0.91)	28	66.7%	87.6%	60.7%	90.2%

AUROC: Area under receiver operating characteristic curve; PPV: Positive predictive value; NPV: Negative predictive value; CLIF-SOFA: Chronic Liver Failure-Sequential Organ Failure Assessment; CLIF-C OF: Chronic Liver Failure Consortium Organ Failure; DF: Discriminant function; ABIC: Age, bilirubin, INR, creatinine; GAHS: Glasgow Alcoholic Hepatitis Score; MELD: Model for end-stage liver disease; MELD-Na: Modified MELD including sodium.