CLIF-AKI score predicts KDIGO stage 3 acute kidney injury in intensive care unit patients with acute-on-chronic liver failure

doi:10.3748/wjg.122612

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World Journal of Gastroenterology

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1007-9327

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Baishideng Publishing Group Inc, 7041 Koll Center Parkway, Suite 160, Pleasanton, CA 94566, USA

Retrospective Cohort Study

Copyright: ©Author(s) 2026. This article is an open access article distributed under the terms and conditions of the Creative Commons Attribution-NonCommercial (CC BY-NC 4.0) license. No commercial re-use. See permissions. Published by Baishideng Publishing Group Inc.

World J Gastroenterol. Dec 28, 2026; 32(48): 122612
Published online Dec 28, 2026. doi: 10.3748/wjg.122612

Table 1 Baseline characteristics and study outcomes of the derivation and validation cohorts, n (%)/median (interquartile range)

Variable	Derivation cohort, n = 1314	Validation cohort, n = 223	P value
Sex			0.153
Female	526 (40.0)	78 (35.0)
Male	788 (60.0)	145 (65.0)
Age, years	57 (50-65)	56 (49-69)	0.983
BMI, kg/m²	28 (24-33)	23 (21-27)	< 0.001^a
MAP, mmHg	60 (53-67)	87 (80-93)	< 0.001^a
Urine output, mL	1225 (750-1900)	1250 (950-1515)	0.421
Comorbidities
Congestive heart failure	177 (13.5)	11 (4.9)	< 0.001^a
Diabetes	307 (23.4)	34 (15.2)	0.007^a
Hypertension	235 (17.9)	59 (26.5)	0.004^a
Fatty liver disease	89 (6.8)	34 (15.2)	< 0.001^a
Organ support
Mechanical ventilation	351 (26.7)	15 (6.7)	< 0.001^a
Vasopressor use	456 (34.7)	13 (5.8)	< 0.001^a
Medications
Antibiotic	1037 (78.9)	103 (46.2)	< 0.001^a
Furosemide	166 (12.6)	107 (48.0)	< 0.001^a
Spironolactone	122 (9.3)	107 (48.0)	< 0.001^a
Human albumin	309 (23.5)	74 (33.2)	0.003^a
Organ failure
Liver	242 (18.4)	108 (48.4)	< 0.001^a
Kidney	401 (30.5)	24 (10.8)	< 0.001^a
Coagulation	312 (23.7)	53 (23.8)	0.994
Brain	326 (24.8)	39 (17.5)	0.018^a
Circulation	456 (34.7)	13 (5.8)	< 0.001^a
Lung	591 (45.0)	25 (11.2)	< 0.001^a
ACLF grade			< 0.001^a
Grade 1	601 (45.7)	192 (86.1)
Grade 2	425 (32.3)	19 (8.5)
Grade 3	288 (21.9)	12 (5.4)
Outcomes
In-hospital mortality	305 (23.2)	36 (16.1)
KDIGO stage 3 AKI within 14 days	452 (34.4)	68 (30.5)
Laboratory tests
Hemoglobin, g/dL	8.50 (7.20-10.10)	10.70 (8.40-12.80)	< 0.001^a
Platelet, × 10⁹/L	82 (52-133)	71 (50-105)	0.001^a
WBC, × 10⁹/L	12 (8-17)	6 (4-9)	< 0.001^a
Albumin, g/dL	2.80 (2.40-3.20)	2.82 (2.42-3.16)	0.545
Anion gap, mmol/L	16.0 (13.0-19.0)	11.3 (9.6-13.8)	< 0.001^a
BUN, mg/dL	26 (16-39)	15 (10-24)	< 0.001^a
Calcium, mmol/L	1.98 (1.83-2.10)	2.07 (1.96-2.16)	< 0.001^a
Chloride, mmol/L	101 (96-106)	102 (97-105)	0.874
Creatinine, mg/dL	1.10 (0.80-1.70)	0.78 (0.64-1.02)	< 0.001^a
Glucose, mmol/L	8.0 (6.5-10.7)	5.5 (4.8-7.0)	< 0.001^a
Sodium, mmol/L	136 (131-139)	136 (133-139)	0.552
Potassium, mmol/L	4.40 (4.00-4.90)	3.80 (3.38-4.21)	< 0.001^a
INR	1.90 (1.50-2.40)	1.97 (1.61-2.44)	0.014^a
PT, seconds	20 (16-26)	22 (19-26)	< 0.001^a
aPTT, seconds	40 (33-54)	44 (39-52)	< 0.001^a
ALT, U/L	38 (23-71)	63 (29-361)	< 0.001^a
ALP, U/L	112 (76-156)	143 (108-195)	< 0.001^a
AST, U/L	80 (46-165)	108 (57-322)	< 0.001^a
TBil, mg/dL	4 (2-9)	12 (7-20)	< 0.001^a
Lymphocytes, %	8 (5-14)	14 (8-22)	< 0.001^a
Monocytes, %	5.0 (3.1-7.3)	8.3 (6.4-10.1)	< 0.001^a
Neutrophils, %	82 (75-88)	75 (67-83)	< 0.001^a
NLR	4 (3-7)	5 (3-10)	0.016^a
RBC, × 10¹²/L	2.55 (2.08-3.08)	3.15 (2.43-3.88)	< 0.001^a
RDW, %	18.1 (15.9-20.8)	15.8 (14.1-18.9)	< 0.001^a
Severity score
MELD	21 (14-28)	25 (22-32)	< 0.001^a
SOFA	8 (6-11)	6 (5-8)	< 0.001^a
MELD-Na	27 (17-40)	27 (23-33)	0.573

^aP < 0.05.

BMI: Body mass index; MAP: Mean arterial pressure; ACLF: Acute-on-chronic liver failure; AKI: Acute kidney injury; WBC: White blood cell; BUN: Blood urea nitrogen; INR: International normalized ratio; PT: Prothrombin time; aPTT: Activated partial thromboplastin time; ALT: Alanine aminotransferase; ALP: Alkaline phosphatase; AST: Aspartate aminotransferase; TBil: Total bilirubin; NLR: Neutrophil-to-lymphocyte ratio; RBC: Red blood cell; MELD: Model for end-stage liver disease; SOFA: Sequential organ failure assessment; MELD-Na: Model for end-stage liver disease-sodium; RDW: Red cell distribution width.

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Table 2 Final multivariable logistic regression model used to develop the chronic liver failure organ failure-acute kidney injury score

Intercept and variable	β coefficient	OR (95%CI)	P value
WBC, × 10⁹/L	0.018	1.02 (1.00-1.04)	0.044
MAP, mmHg	-0.020	0.98 (0.97-0.99)	< 0.001
BUN, mg/dL	0.011	1.01 (1.00-1.02)	0.005
MELD score	0.057	1.06 (1.04-1.08)	< 0.001
BMI, kg/m²	0.054	1.05 (1.04-1.07)	< 0.001
Albumin, g/dL	-0.426	0.65 (0.52-0.81)	< 0.001
Mechanical ventilation	0.977	2.66 (1.99-3.54)	< 0.001
Vasopressor use	0.797	2.22 (1.68-2.93)	< 0.001
Intercept	-2.409

The predicted probability of acute kidney injury stage 3 was calculated as: P = 1/{1 + exp[-(-2.409 + 0.797 × “vasopressor use = 1” + 0.977 × “mechanical ventilation = 1” - 0.020 × mean arterial pressure + 0.018 × white blood cell + 0.011 × blood urea nitrogen - 0.426 × albumin + 0.054 × body mass index + 0.057 × model for end-stage liver disease)]}. Vasopressor use and mechanical ventilation were coded as binary variables (yes = 1, no = 0), whereas the remaining six predictors were treated as continuous variables. OR: Odds ratio; CI: Confidence interval; WBC: White blood cell; MAP: Mean arterial pressure; BUN: Blood urea nitrogen; MELD: Model for end-stage liver disease; BMI: Body mass index.

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Table 3 Chronic liver failure organ failure-acute kidney injury risk score and risk stratification

Variables	Points	Variables	Points
WBC, × 10⁹/L		BUN, mg/dL
≤ 5	0	≤ 15	0
5-10	15	16-25	5
11-15	25	26-40	10
> 15	30	> 40	15
Albumin, g/dL		BMI, kg/m²
≥ 3.5	0	≤ 23.9	0
3.0-3.4	10	24.0-27.9	10
2.5-2.9	15	28.0-34.9	20
< 2.5	20	≥ 35.0	30
MAP in mmHg		Mechanical ventilation
> 65	0	Yes	35
56-65	10	No	0
≤ 55	20
MELD score		Vasopressor use
≤ 15	0	Yes	30
16-25	15	No	0
26-35	35
> 35	60
Risk stratification, CLIF-AKI score	Risk category
> 140	Very high risk
111-140	High risk
81-110	Moderate risk
≤ 80	Low risk

WBC: White blood cell; MAP: Mean arterial pressure; MELD: Model for end-stage liver disease; CLIF-AKI: Chronic liver failure organ failure-acute kidney injury; BMI: Body mass index; BUN: Blood urea nitrogen.

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Table 4 Proportion of patients identified at each chronic liver failure organ failure-acute kidney injury score threshold and diagnostic performance for predicting KDIGO stage 3 acute kidney injury within 14 days, 95% confidence interval

Variable	Chronic liver failure organ failure-acute kidney injury score
Variable	> 80	> 110	> 140
No. of patients, n (%)	937 (71.3)	611 (46.5)	288 (21.9)
Sensitivity	0.91 (0.88-0.94)	0.73 (0.69-0.77)	0.45 (0.41-0.50)
Specificity	0.39 (0.36-0.42)	0.68 (0.64-0.71)	0.90 (0.88-0.92)
Positive predictive value	0.44 (0.41-0.47)	0.54 (0.50-0.58)	0.71 (0.66-0.76)
Negative predictive value	0.89 (0.86-0.92)	0.83 (0.80-0.86)	0.76 (0.73-0.79)

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Table 5 Continuous net reclassification improvement and integrated discrimination improvement of the chronic liver failure organ failure-acute kidney injury model compared with PIRO, Child-Turcotte-Pugh, chronic liver failure consortium acute-on-chronic liver failure, model for end-stage liver disease, and model for end-stage liver disease-sodium scores for predicting stage 3 acute kidney injury in the external validation cohort

Comparator model	NRI (95%CI)	P value	IDI (95%CI)	P value
PIRO	0.408 (0.126-0.696)	0.008	0.093 (0.037-0.149)	0.004
CTP	1.162 (0.916-1.391)	< 0.001	0.271 (0.209-0.334)	< 0.001
CLIF-C-ACLF	1.000 (0.758-1.242)	< 0.001	0.212 (0.151-0.275)	< 0.001
MELD	1.117 (0.858-1.353)	< 0.001	0.307 (0.237-0.377)	< 0.001
MELD-Na	1.061 (0.802-1.305)	< 0.001	0.294 (0.224-0.362)	< 0.001

CI: Confidence interval; IDI: Integrated discrimination improvement; NRI: Net reclassification improvement; CTP: Child-Turcotte-Pugh; CLIF-C-ACLF: Chronic liver failure consortium acute-on-chronic liver failure; MELD: Model for end-stage liver disease; MELD-Na: Model for end-stage liver disease-sodium.

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Citation: Wang N, Tan YW, Zhang PF, Zhou XB, Zhu L. CLIF-AKI score predicts KDIGO stage 3 acute kidney injury in intensive care unit patients with acute-on-chronic liver failure. World J Gastroenterol 2026; 32(48): 122612
URL: https://www.wjgnet.com/1007-9327/full/v32/i48/122612.htm
DOI: https://dx.doi.org/10.3748/wjg.122612

Wang N, Tan YW, Zhang PF, Zhou XB, Zhu L. CLIF-AKI score predicts KDIGO stage 3 acute kidney injury in intensive care unit patients with acute-on-chronic liver failure. World J Gastroenterol 2026; 32(48): 122612 [DOI: 10.3748/wjg.122612]

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