Chronic Liver Failure Consortium — ACLF Prognostic Score
Predicts 28-day and 90-day mortality in acute-on-chronic liver failure (ACLF). Combines CLIF-SOFA organ failure assessment with age and white cell count. Validated across European and Asian multicentre cohorts.
WBC = white blood cell count. ln = natural logarithm. Each organ scored 0–3 (liver and coagulation max 2, circulation max 2). Maximum CLIF-SOFA = 15.
| Organ | Score 0 | Score 1 | Score 2 | Score 3 |
|---|---|---|---|---|
| Liver | <102 μmol/L | 102–204 | >204 | — |
| Kidney | <106 μmol/L | 106–353 | 353–442 | ≥442 or RRT |
| Brain (WH) | Grade 0 | Grade 1–2 | Grade 3 | Grade 4 |
| Coagulation | INR <2.0 | INR 2.0–2.5 | INR >2.5 | — |
| Circulation | MAP ≥70 | MAP <70 | Vasopressors | — |
| Respiratory | >300 / 357 | 201–300 / 214–357 | 101–200 / 89–214 | ≤100 / 89 |
Respiratory values: PaO₂/FiO₂ / SpO₂/FiO₂ thresholds.
ACLF is diagnosed in patients with acute decompensation of cirrhosis and at least one of the following organ failures defined by CLIF-SOFA:
The number of organ failures determines the ACLF grade: ACLF Grade I = 1 organ failure; Grade II = 2 organ failures; Grade III = ≥3 organ failures. Higher grade correlates with markedly worse short-term prognosis.
| CLIF-C ACLF | 28-day Mortality | 90-day Mortality | Risk Category |
|---|---|---|---|
| <30 | ~14% | ~20% | Lower risk |
| 30–34 | ~35% | ~45% | Moderate risk |
| 35–39 | ~55% | ~65% | High risk |
| 40–44 | ~65% | ~75% | Very high risk |
| ≥45 | ~75% | ~90% | Critical |
ACLF Grading and Transplant Urgency: ACLF grade directly informs transplant urgency listing. Grade I patients may stabilise with optimal medical management. Grade II patients require close HDU/ICU monitoring and expedited transplant workup. Grade III patients have the highest short-term mortality and should be assessed urgently for transplant candidacy.
Liver transplantation remains the key life-saving intervention in ACLF. Patients with ACLF grade III who show a response to 3–7 days of intensive treatment may be reassessed; non-responders have very high mortality without transplant. CLIF-C ACLF score is superior to MELD alone for short-term prognostication in ACLF.
ICU management focuses on vasopressor support for circulatory failure, renal replacement therapy for hepatorenal syndrome/AKI, and lung-protective ventilation for respiratory failure. Concurrent management of precipitating events (infection, alcohol, reactivation) is essential.
CLIF-C vs MELD in transplant prioritisation: While MELD is used for standard organ allocation, CLIF-C ACLF provides better short-term (28- and 90-day) mortality prediction specifically in ACLF. Some transplant programmes incorporate CLIF-C score alongside MELD to identify patients at highest immediate risk who may benefit most from urgent listing.