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Evaluating Prognosis of Patients With Acute‐On‐Chronic Liver Failure: Is the Simplest Score Good Enough?

This letter regards a study by O’Leary et al.,(1) in which authors validated in patients with or without infections the definition of acute-on-chronic liver failure (ACLF) previously published by the North American Consortium for the Study of End-Stage Liver Disease (NACSELD) in a sample exclusively composed of infected individuals. The new study demonstrated that the NACSELD definition of ACLF is associated with lower 30-day survival and suggested that it could be used as a simple prognostic tool.(1) Nevertheless, we understand that this subject deserves further discussion. There is no doubt that the NACSELD definition of ACLF and the score derived from it are simpler than those proposed by the Chronic Liver Failure Consortium (CLIF-C). On the other hand, the NACSELD definition and score are excessively restrictive, including only 10% of patients admitted for acute decompensation of cirrhosis, while the CLIF-C definition determined the diagnosis of ACLF in over 30% of patients with cirrhosis with acute decompensation in the original cohort and in validation cohorts, such as the one recently published by us.(2) Besides being more sensitive for the diagnosis of ACLF, the CLIF-C definition is also highly associated with lower 30-day survival rates and even with significantly lower rates than the definition proposed by the Asian Pacific Association for the Study of the Liver,(3) compared to which the NACSELD definition demonstrated a tendency of superiority.(1) Another issue of discussion is the suggestion to limit resources used in patients with many organ failures. We understand that evidence is scarce regarding definitions of futility of care for these patients and that general recommendations should not be made at this time.(4) A recent study demonstrated similar 12-month survival rates for transplanted patients with ACLF grade 3 according to CLIF-C definition when compared to transplanted patients with ACLF grade ≤2 or without ACLF.(5) In conclusion, despite the benefits of a simple definition of ACLF, we believe that a more comprehensive one would probably lead to better care for these extremely ill patients, enabling them to reach transplantation. Studies comparing both NACSELD and CLIF-C definitions could bring clarity to this matter.