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    Attention COACH STUDY participants:

    The principal investigators of the study request that you use the official version of the modified score here.

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

    Predicts mortality in acute-on-chronic liver failure.

    INSTRUCTIONS

    Use in adult patients with decompensated chronic (cirrhotic) liver disease; it does not predict outcome in acute liver failure.

    When to Use
    Pearls/Pitfalls
    Why Use

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

    • 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.

    • 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.

    years
    × 10³ cells/µL
    Liver
    <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
    <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
    0
    +1
    1-2
    +2
    3-4
    +3
    Coagulation
    <2.0
    +1
    2.0 to <2.5
    +2
    ≥2.5
    +3
    Circulatory
    ≥70
    +1
    <70
    +2
    Any MAP with vasopressors
    +3
    Respiratory
    PaO₂/FiO₂ ratio
    SpO₂/FiO₂ ratio
    >300
    +1
    >200 to 300
    +2
    ≤200 (or if patient intubated for respiratory failure)
    +3

    Result:

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    Next Steps
    Evidence
    Creator Insights
    Dr. Rajiv Jalan

    About the Creator

    Rajiv Jalan, MBBS, MRCP, is a professor of hepatology at the Institute for Liver and Digestive Health at University College London in UK. Dr. Jalan’s primary research is focused on acute-on-chronic liver failure.

    To view Dr. Rajiv Jalan's publications, visit PubMed

    Are you Dr. Rajiv Jalan? Send us a message to review your photo and bio, and find out how to submit Creator Insights!
    MDCalc loves calculator creators – researchers who, through intelligent and often complex methods, discover tools that describe scientific facts that can then be applied in practice. These are real scientific discoveries about the nature of the human body, which can be invaluable to physicians taking care of patients.
    Content Contributors
    • Callum Wood, MB, BChir, MRCP (UK)
    About the Creator
    Dr. Rajiv Jalan
    Are you Dr. Rajiv Jalan?
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    Content Contributors
    • Callum Wood, MB, BChir, MRCP (UK)