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
ARTICLE HIGHLIGHTS
Research background

There is no consensus on the definition of acute on chronic liver failure. We had recently shown that the definition proposed by the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) is more sensitive to identify acute on chronic liver failure and has a better ability to predict all-cause and short-term mortality than that were proposed by the North American Consortium for the Study of End-Stage Liver Disease.

Research motivation

One of the major criticisms of EASL-CLIF criteria is that it is more complicated to use in clinical practice.

Research objectives

In this study, using a large dataset, our objective was to develop an easier to use model that will be easier to use in clinical practice.

Research methods

We initially assessed the prevalence of type and frequency of organ failures (OF) using EASL-CLIF. Using the same dataset, we developed modified criteria as described later under 'model development'. Patients were followed until the event date or were censored at the end of 30-ds after listing. To improve the EASL-CLIF criteria, we determined the best cutoff values for serum creatinine and international normalized ratio (INR) that were associated with higher mortality. We used a subset of patients (n = 1445) with information on glomerular filtrations rate to determine the best cutoff values for serum creatinine levels. After identifying the best serum creatinine value, we identified the optimal INR cutoff. Using the above values, we then developed a modified 6-organ failure criteria modified EASL-CLIF (mEACLF). We compared our new mEACLF criteria with the original EASL-CLIF criteria by looking at the distribution of OF, acute-on-chronic liver failure (ACLF) grades, and 30-d all-cause and transplant-free mortality rates.

Research results

The area under the receiver operating characteristic (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).

Research conclusions

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

Research perspectives

To advance ACLF research in a meaningful manner, it is essential to have easy-to-use criteria. We believe that the modified EASL-CLIF criteria are an important step in that direction.