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The NACSELD-ACLF Score Accurately Predicts Survival: An External Validation Using a National Cohort.

Acute-on-chronic liver failure (ACLF) carries high short-term mortality. The North American Consortium for the Study of End-Stage Liver Disease (NACSELD) ACLF score, positive if ≥2 organ failures are present, is a bedside tool that predicts short-term mortality in patients with cirrhosis. However, it was created using major liver referral centers, where a minority of patients with cirrhosis are hospitalized. Therefore, this study utilized the Nationwide Inpatient Sample, a nationally-representative database, from 2005-2014 to externally validate the NACSELD-ACLF score in a cohort of patients with decompensated cirrhosis, who were identified by a validated algorithm. Organ failures were identified using diagnosis codes. The primary objective was to evaluate the association between the NACSELD-ACLF score and inpatient mortality, while secondary objectives compared outcomes depending on presence of infection or hospitalization at a transplant center. Multivariable logistic regression was utilized to compare outcomes and area under the curve was calculated. 1,523,478 discharges were included with 106,634 (7.0%) having a positive NACSELD-ACLF score. Patients were a mean 58 years old and mostly white men. Infection was present in 33.7% of the sample. Inpatient survival decreased with each organ failure and if infection was present. Patients with the NACSELD-ACLF score had significantly lower inpatient survival on crude (94.2% vs. 47.8%, p<0.001) and multivariable analysis (OR 0.08, 95% CI 0.07-0.08), AUROC 0.77 (95% CI 0.77-0.78). Liver transplant centers had clinically similar but significantly better survival at each number of organ failure, in patients with the NACSELD-ACLF score, and on multivariable analysis (OR 1.17, 95% CI 1.13-1.22). Conclusion: Using a national cohort, our study validated the NACSELD-ACLF score as an excellent, simple bedside tool to predict short-term survival in patients with decompensated cirrhosis.