title: 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.
abstract: OBJECTIVE
  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% (χ(2) for trend, P = 0.002) and 90-d mortality was 16.7%, 27.3%, 78.6% and 100% (χ(2) 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).
  
  
  CONCLUSIONS
  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.
authors.affiliation: Radha K Dhiman, Swastik Agrawal, Tarana Gupta, Ajay Duseja, Yogesh Chawla, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
authors.forename: Radha K
authors.initials: RK
authors.lastname: Dhiman
authors.affiliation: Radha K Dhiman, Swastik Agrawal, Tarana Gupta, Ajay Duseja, Yogesh Chawla, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
authors.forename: Swastik
authors.initials: S
authors.lastname: Agrawal
authors.affiliation: Radha K Dhiman, Swastik Agrawal, Tarana Gupta, Ajay Duseja, Yogesh Chawla, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
authors.forename: Tarana
authors.initials: T
authors.lastname: Gupta
authors.affiliation: Radha K Dhiman, Swastik Agrawal, Tarana Gupta, Ajay Duseja, Yogesh Chawla, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
authors.forename: Ajay
authors.initials: A
authors.lastname: Duseja
authors.affiliation: Radha K Dhiman, Swastik Agrawal, Tarana Gupta, Ajay Duseja, Yogesh Chawla, Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh 160012, India.
authors.forename: Yogesh
authors.initials: Y
authors.lastname: Chawla
mesh_terms: D018806:APACHE; D065290:Acute-On-Chronic Liver Failure / Q000175:diagnosis* / Q000208:ethnology / Q000401:mortality / Q000628:therapy; D000328:Adult; D000368:Aged; D019540:Area Under Curve; D044466:Asian People; D016009:Chi-Square Distribution; D003661:Decision Support Techniques; D005260:Female; D006801:Humans; D007194:India / Q000453:epidemiology; D008103:Liver Cirrhosis / Q000175:diagnosis* / Q000208:ethnology / Q000401:mortality; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D016017:Odds Ratio; D063305:Organ Dysfunction Scores; D011237:Predictive Value of Tests; D011379:Prognosis; D011446:Prospective Studies; D012372:ROC Curve; D018570:Risk Assessment; D012307:Risk Factors; D016019:Survival Analysis; D013997:Time Factors; D055815:Young Adult
keywords: Acute decompensation; Acute on chronic liver failure; Cirrhosis; Mortality; Prognosis