Observational Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Feb 27, 2022; 14(2): 420-428
Published online Feb 27, 2022. doi: 10.4254/wjh.v14.i2.420
Modified EASL-CLIF criteria that is easier to use and perform better to prognosticate acute-on-chronic liver failure
Paul J Thuluvath, Feng Li
Paul J Thuluvath, Feng Li, Institute of Digestive Health and Liver Diseases, Mercy Medical Center, Baltimore, MD 21202, United States
Paul J Thuluvath, Department of Medicine, University of Maryland School of Medicine, Baltimore, MD 21202, United States
Author contributions: Thuluvath PJ contributed to the study concept, design, analysis, interpretation of data, and drafting of the manuscript; Li F did the statistical analysis, contributed to the interpretation of data, and drafted the statistical part of the manuscript.
Institutional review board statement: The study was done using a national database (UNOS) that is publicly available. The datasets are de-identified and therefore exempt from IRB approval.
Informed consent statement: This study is based on a de-identified national database (UNOS) and informed consent is not applicable.
Conflict-of-interest statement: There are no conflicts of interest to report.
Data sharing statement: Available to public from the UNOS.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
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: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Paul J Thuluvath, FAASLD, AGAF, FACG, FRCP, Professor, Institute of Digestive Health and Liver Diseases, Mercy Medical Center, 301 Saint Paul Place, Baltimore, MD 21202, United States. thuluvath@gmail.com
Received: October 26, 2021
Peer-review started: October 26, 2021
First decision: December 27, 2021
Revised: January 1, 2022
Accepted: January 29, 2022
Article in press: January 29, 2022
Published online: February 27, 2022
Processing time: 118 Days and 23 Hours
Abstract
BACKGROUND

We have recently shown that the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria showed a better sensitivity to detect acute-on-chronic liver failure (ACLF) with a better prognostic capability than the North American Consortium for the Study of End-Stage Liver Disease criteria.

AIM

To simplify EASL-CLIF criteria for ease of use without sacrificing its sensitivity and prognostic capability.

METHODS

Using the United Network for Organ Sharing data (January 11, 2016, to August 31, 2020), we modified EASL-CLIF (mEACLF) criteria; the modified mEACLF criteria included six organ failures (OF) as in the original EASL-CLIF, but renal failure was defined as creatinine ≥ 2.35 mg/dL and coagulation failure was defined as international normalized ratio (INR) ≥ 2.0. The mEACLF grades (0, 1, 2, and ≥ 3) directly reflected the number of OF.

RESULTS

Of the 40357 patients, 14044 had one or more OF, and 9644 had ACLF grades 1-3 by EASL-CLIF criteria. By the mEACLF criteria, 15574 patients had one or more OF. The area under the receiver operating characteristic (AUROC) for 30-d all-cause mortality by OF was 0.842 (95%CI: 0.831-0.853) for mEACLF and 0.835 (95%CI: 0.824-0.846) for EASL-CLIF (P = 0.006), and AUROC for 30-d transplant-free mortality by OF was 0.859 (95%CI: 0.849-0.869) for mEACLF and 0.851 (95%CI: 0.840-0.861) for EASL-CLIF (P = 0.001). The AUROC of 30-d all-cause mortality by ACLF grades was 0.842 (95%CI: 0.831-0.853) for mEACLF and 0.793 (95%CI: 0.781-0.806) for EASL-CLIF (P < 0.0001). The AUROC of 30-d transplant-free mortality by ACLF was 0.859 (95%CI: 0.848-0.869) for mEACLF and 0.805 (95%CI: 0.793-0.817) for EASL-CLIF (P < 0.0001).

CONCLUSION

Our study showed that EASL-CLIF criteria for ACLF grades could be simplified for ease of use without losing its prognostication capability and sensitivity.

Keywords: Acute on chronic liver failure; Organ failure; 30-d transplant-free mortality; Liver transplantation; EASL-CLIF criteria

Core Tip: There is no consensus on the best definition for acute-on-chronic liver failure (ACLF). The most common definition used in the literature is the one proposed European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) consortium. One problem with those criteria is that it is not very user-friendly. We have shown that EASL-CLIF criteria for ACLF could be simplified without losing its sensitivity and ability to prognosticate 30-d all-cause and transplant-free mortality. We believe that modified EASL-CLIF criteria; the modified criteria that we propose are easier to use than the EASL-CLIF criteria and also have a better prognostic capability.