CLIF-C ACLF (Acute-on-Chronic Liver Failure)

CLIF-C ACLF Calculator

Age

years

White Blood Cell Count

×10⁹/L

Liver Failure (Bilirubin ≥12 mg/dL)

Kidney Failure (Creatinine ≥2 mg/dL or Renal Replacement)

Brain Failure (HE Grade III-IV)

Coagulation Failure (INR ≥2.5)

Circulation Failure (Use of Vasopressors)

Respiratory Failure (PaO₂/FiO₂ ≤200 or SpO₂/FiO₂ ≤214)

Organ Failures: 0

No ACLF

0 organ failures. 28-day mortality: ~5%.

Predicts mortality in acute-on-chronic liver failure.

Why Use

May be used to predict 1-, 3-, 6- and 12-month mortality. A predicted mortality of 100% after 48 hours of ICU treatment might give insights on futility of ongoing organ support. The score can be used dynamically; an increasing score despite intensive organ support might prompt a discussion about withdrawal of treatment, whereas a decrease in score after 48 hours might suggest a positive response to treatment.

When to Use

Adult patients with decompensated cirrhotic liver disease and a clinical suspicion of failure of one or more organ systems.

Formula

CLIF-C ACLF Score = 10 x [0.33 x CLIF Organ Failure Score + 0.04 x age, years + 0.63 x ln(WBC count, 10 9 cells/L) - 2], where CLIF Organ Failure Score = addition of the selected points: Variable Points Liver Bilirubin <6 mg/dL (<102.6 µmol/L) 1 6 to <12 mg/dL (102.6 to <205.2 µmol/L) 2 ≥12 mg/dL (≥205.2 µmol/L) 3 Kidney Creatinine <2 mg/dL (<176.8 µmol/L) 1 2 to <3.5 mg/dL (176.8 to <309.4 µmol/L) 2 ≥3.5 mg/dL (≥309.4 µmol/L) or renal replacement therapy 3 Brain West-Haven Grade for Hepatic Encephalopathy 0 1 1-2 2 3-4 (or if patient is intubated due to hepatic encephalopathy and not respiratory failure*) 3 Coagulation INR <2.0 1 2.0 to <2.5 2 ≥2.5 3 Circulatory MAP , mmHg ≥70 1 <70 2 Any MAP with vasopressors 3 Respiratory (use PaO 2 /FiO 2 ratio or SpO 2 /FiO 2 ratio) PaO 2 / FiO 2 ratio >300 1 >200 to 300 2 ≤200 (or if patient intubated for respiratory failure) 3 SpO 2 / FiO 2 ratio >357 1 >214 to 357 2 ≤214 (or if patient intubated for respiratory failure) 3 *Patients submitted to mechanical ventilation due to hepatic encephalopathy and not due to a respiratory failure are considered as presenting a cerebral failure (cerebral subscore = 3).

Pearls / Pitfalls

Decompensated liver disease is generally defined as the development of jaundice, ascites, encephalopathy, upper GI bleed, bacterial infection, or a combination of these, in a patient with existing cirrhotic liver disease. ACLF is a relatively new concept, characterized by a systemic inflammatory response as well as multiple organ failures (including decompensation of chronic liver disease). Short term mortality in ACLF is high, around 25-75% at 28 days ( Moreau 2013 ). The first part of the score counts the number of failing organ systems; the second part incorporates age and white cell count to calculate an ACLF score and a predicted mortality rate. A score of >65 is associated with 100% mortality 3-7 days after diagnosis of ACLF. In up to 50% of patients, the precipitating cause of ACLF remains unidentified. Common causes include sepsis, ongoing alcohol consumption, and relapse of viral hepatitis. This study is not validated in or designed for use in patients with acute liver failure (for example, those with acetaminophen overdose or fulminant but de novo viral hepatitis) in the absence of pre-existing chronic liver disease. The derivation and validation studies were trialed in patients admitted to a critical care unit; therefore, its accuracy with regards to patients who are managed medically without a higher level care is not known.

Management

There is no single specific treatment for ACLF. Management is focused on organ support and treatment of reversible causes. Remember that sepsis can often be difficult to spot in patients with cirrhosis. Infection was identified as a potential precipitating factor in around a third of patients in the derivation study. Take blood, urine, and ascitic fluid samples to identify possible infection. Consider empiric use of antibiotics.

Critical Actions

Discuss with the patient and with critical care colleagues as appropriate regarding options for escalation of care.

Advice

The score can be recalculated after 48 hours as a marker of response to treatment. If there is no acute-on-chronic liver failure (ACLF grade 0), the CLIF-C AD (acute decompensation) score can be used instead to predict mortality.

More Information

Interpretation: Probability of death at a given time = 1 - e y , where y = -CI x exp(β x CLIF-C ACLF Score), where Cl and β are as follows: Time Cumulative baseline hazard (Cl) Coefficient (β) 1 month 0.0022 0.0995 3 months 0.0079 0.0869 6 months 0.0115 0.0824 1 year 0.0231 0.0731 From Jalan 2014 .