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Liver failure determines the outcome in patients of acute-on-chronic liver failure (ACLF): comparison of APASL ACLF research consortium (AARC) and CLIF-SOFA models


Background and aims

Acute-on-chronic liver failure (ACLF) is a progressive disease associated with rapid clinical worsening and high mortality. Early prediction of mortality and intervention can improve patient outcomes. We aimed to develop a dynamic prognostic model and compare it with the existing models.


A total of 1402 ACLF patients, enrolled in the APASL-ACLF Research Consortium (AARC) with 90-day follow-up, were analyzed. An ACLF score was developed in a derivation cohort (n = 480) and was validated (n = 922).


The overall survival of ACLF patients at 28 days was 51.7%, with a median of 26.3 days. Five baseline variables, total bilirubin, creatinine, serum lactate, INR and hepatic encephalopathy, were found to be independent predictors of mortality, with AUROC in derivation and validation cohorts being 0.80 and 0.78, respectively. AARC-ACLF score (range 5–15) was found to be superior to MELD and CLIF SOFA scores in predicting mortality with an AUROC of 0.80. The point scores were categorized into grades of liver failure (Gr I: 5–7; II: 8–10; and III: 11–15 points) with 28-day cumulative mortalities of 12.7, 44.5 and 85.9%, respectively. The mortality risk could be dynamically calculated as, with each unit increase in AARC-ACLF score above 10, the risk increased by 20%. A score of ≥11 at baseline or persisting in the first week was often seen among nonsurvivors (p = 0.001).


The AARC-ACLF score is easy to use, dynamic and reliable, and superior to the existing prediction models. It can reliably predict the need for interventions, such as liver transplant, within the first week.

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APASL ACLF research consortium


Acute-on-chronic liver failure


Hepatitis A virus


Hepato-cellular carcinoma


Hepatitis E virus


Hepatitis B virus


Severe alcoholic hepatitis


Trans-jugular liver biopsy


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Corresponding author

Correspondence to S. K. Sarin.

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Conflict of interest

The authors declare that they have no conflict of interest.

Ethical approval

Approval of the institutional ethics committees was obtained.

Informed consent

Informed consent was taken from the patient or the next of kin.

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Electronic supplementary material



The study was approved by institute ethical committee vide letter no F/25/5/64/AC2013/912 and the respective centers also had their own ethical board approval for the study to be carried out. The centers, investigators and the number of patients contibuted are listed as follows:

Center no. Name Country/center Total patients
1 Dr. Shiv K Sarin ILBS, India 1286
5 Dr. Mamun-Al Mahtab Bangladesh 145
6 Dr. Yogesh Chawala Chandigarh 128
9 Dr. Tan SS Malaysia 109
3 Dr. Harshad Devarbhavi Bangalore 103
2 Dr. Zhongping Duan Beijing 98
21 Dr. Qin Ning, Jidong Jia, China 96
14 Dr. Deepak Naryan Bombay Hospital 76
4 Dr. Eapen Vellore 72
8 Dr. Saeed Hamid Karachi, Pakistan 69
22 Dr. Kim  Republic of Korea 68
13 Dr. Hasmik Armenia 50
10 Dr. Guan Huei Lee Singapore 39
7 Dr. Ajit sood Ludhiana, India 34
12 Dr. Laurentius A. Lesmana Indonesia 28
17 Dr. Zaigham Abbas Pakistan 25
23 Dr. Gamal Shiha Egypt 25
11 Dr. Diana Alcantara-Payawal Philippines 21
20 Dr. A. Kadir Dokmeci Turkey 19
16 Dr. Jose Philippines 12
24 Dr. Man-Fung Yuen Hong Kong 12
15 Dr. George K Lau China 10
18 Dr. Fazal Karim Bangladesh 6
19 Dr. P N Rao Hyderabad, India 4
Total    2535
Complete data for analysis 1402

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Choudhury, A., Jindal, A., Maiwall, R. et al. Liver failure determines the outcome in patients of acute-on-chronic liver failure (ACLF): comparison of APASL ACLF research consortium (AARC) and CLIF-SOFA models. Hepatol Int 11, 461–471 (2017).

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  • Cirrhosis
  • ACLF
  • AARC score
  • Organ failure
  • Liver failure