Systematic Reviews
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Dec 27, 2022; 14(12): 2025-2043
Published online Dec 27, 2022. doi: 10.4254/wjh.v14.i12.2025
CLIF-SOFA and CLIF-C scores for the prognostication of acute-on-chronic liver failure and acute decompensation of cirrhosis: A systematic review
Ebrahim Rashed, Jonathan Soldera
Ebrahim Rashed, Jonathan Soldera, Acute Medicine, University of South Wales, Cardiff CF37 1DL, United Kingdom
Author contributions: Both authors contributed to writing and reviewing the final draft of the manuscript.
Conflict-of-interest statement: All the authors declare no conflict of interest.
PRISMA 2009 Checklist statement: PRISMA 2009 was observed, and a PRISMA figure is included in the manuscript.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See:
Corresponding author: Jonathan Soldera, MD, MSc, Associate Professor, Staff Physician, Acute Medicine, University of South Wales, Llantwit Rd, Pontypridd, Cardiff CF37 1DL, United Kingdom.
Received: August 26, 2022
Peer-review started: August 26, 2022
First decision: October 11, 2022
Revised: October 18, 2022
Accepted: November 7, 2022
Article in press: November 7, 2022
Published online: December 27, 2022
Processing time: 119 Days and 9.7 Hours

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by decompensation in individuals with chronic liver disease, generally secondary to one or more extra-hepatic organ failures, implying an elevated mortality rate. Acute decompensation (AD) is the term used for one or more significant consequences of liver disease in a short time and is the most common reason for hospital admission in cirrhotic patients. The European Association for the Study of Liver-Chronic-Liver Failure (EASL-CLIF) Group modified the intensive care Sequential Organ Failure Assessment score into CLIF-SOFA, which detects the presence of ACLF in patients with or without AD, classifying it into three grades.


To investigate the role of the EASL-CLIF definition for ACLF and the ability of CLIF-SOFA, CLIF-C ACLF, and CLIF-C AD scores for prognosticating ACLF or AD.


This study is a literature review using a standardized search method, conducted using the steps following the guidelines for reporting systematic reviews set out by the PRISMA statement. For specific keywords, relevant articles were found by searching PubMed, ScienceDirect, and BioMed Central-BMC. The databases were searched using the search terms by one reviewer, and a list of potentially eligible studies was generated based on the titles and abstracts screened. The data were then extracted and assessed on the basis of the Reference Citation Analysis (


Most of the included studies used the EASL-CLIF definition for ACLF to identify cirrhotic patients with a significant risk of short-term mortality. The primary outcome in all reviewed studies was mortality. Most of the study findings were based on an area under the receiver operating characteristic curve (AUROC) analysis, which revealed that CLIF-SOFA, CLIF-C ACLF, and CLIF-C AD scores were preferable to other models predicting 28-d mortality. Their AUROC scores were higher and able to predict all-cause mortality at 90, 180, and 365 d. A total of 50 articles were included in this study, which found that the CLIF-SOFA, CLIF-C ACLF and CLIF-C AD scores in more than half of the articles were able to predict short-term and long-term mortality in patients with either ACLF or AD.


CLIF-SOFA score surpasses other models in predicting mortality in ACLF patients, especially in the short-term. CLIF-SOFA, CLIF-C ACLF, and CLIF-C AD are accurate short-term and long-term mortality prognosticating scores.

Keywords: End-stage liver disease, Acute-on-chronic liver failure, CLIF-SOFA, CLIF-C ACLF, CLIF-C AD

Core Tip: Acute-on-chronic liver failure (ACLF) is a serious medical challenge worldwide, and its occurrence is a difficult clinical incident due to its severe presentation, quick disease course, and elevated short-term mortality. The European Association for the Study of Liver-Chronic-Liver Failure (EASL-CLIF) Consortium proposal has gained considerable acceptance as a diagnostic criteria for ACLF. CLIF-SOFA has increased the ability to detect patients with ACLF. Unless presenting with renal impairment and/or mild to moderate hepatic encephalopathy, cirrhotic patients with acute decompensation and single liver failure (or any other single "non-renal" organ failure) had a minimum mortality risk. These results suggest that CLIF-SOFA score surpasses other models in predicting mortality in ACLF patients, especially in the short-term.