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. 2025 Aug 7:gutjnl-2025-335651.
doi: 10.1136/gutjnl-2025-335651. Online ahead of print.

Performance of the China-CLIF framework in acute-on-chronic liver failure: a multicohort study across all aetiologies

Jinjin Luo #  1 , Meiqian Hu #  1 , Tingting Feng #  2 , Liyuan Zhang #  1   3 , Yan Huang #  4 , Yuxian Huang #  5 , Feng Ye #  6 , Jiang Li #  7 , Ferran Aguilar  8 , Cristina Sánchez-Garrido  8 , Eva Usón-Raposo  8 , Bing Zhu  9 , Qian Zhou  1 , Xi Liang  1 , Jiaqi Li  10 , Peng Li  11 , Jiaojiao Xin  1 , Dongyan Shi  1 , Jianming Zheng  5 , Huafen Zhang  1 , Baoju Wang  12 , Wei Qiang  1 , Heng Yao  1 , Xingping Zhou  1 , Jiaxian Chen  1 , Wen Hu  1 , Bingqi Li  1 , Shiwen Ma  1 , Xiao Wu  1 , Xiao Li  1 , Yuheng Kong  1 , Feiyang Sun  13 , Xi Chen  14 , Tianzhou Wu  15 , Lingling Yang  16 , Suwan Sun  17 , Beibei Guo  10 , Lulu He  18 , Jinjun Chen  19 , Shaojie Xin  9 , Xue Li  20 , Huazhong Chen  21 , Paolo Angeli  22   23 , Rajiv Jalan  22   24 , Bingliang Lin  25 , Yu Chen  26 , Shaoli You  27 , Xin Chen  28   29 , Alberto Queiroz Farias  30 , Jonel Trebicka  22   31 , Jing Jiang  32 , Richard Moreau  22   33   34 , Jun Li  32 ; CANONIC, PREDICT, ACLARA Study Group; Chinese Group on the Study of Severe Hepatitis B (COSSH)
Collaborators, Affiliations
Free article

Performance of the China-CLIF framework in acute-on-chronic liver failure: a multicohort study across all aetiologies

Jinjin Luo et al. Gut. .
Free article

Abstract

Background: Acute-on-chronic liver failure (ACLF) of various aetiologies is a complex syndrome with high short-term mortality and significant global burden.

Objective: To explore easily applicable diagnostic criteria and an accurate prognostic score for ACLF.

Design: Clinical data from 5288 patients (after exclusions from 7388 screened) with acute deterioration of chronic liver disease across various aetiologies were used to evaluate the performance of European Chronic Liver Failure (CLIF) and Chinese Group on the Study of Severe Hepatitis B (COSSH) criteria. Three non-Asian cohorts were performed to validate the results.

Results: CLIF criteria categorised 844 patients as ACLF (28-day/90-day liver transplantation (LT)-free mortality: 40.7%/57.0%; 321 with non-hepatitis B virus (HBV) aetiology, 523 with HBV aetiology), while COSSH criteria categorised 2038 patients as ACLF (mortality: 27.3%/41.0%; 602 with non-HBV aetiology, 1436 with HBV aetiology). COSSH criteria identified 22.6% (1194/5288) more patients (mortality: 19.1%/31.4%) compared with CLIF criteria, including 14.2% non-HBV patients (mortality: 15.9%/33.3%). COSSH criteria produced a more reasonable epidemiological pyramid-like distribution across severity grades (grades 1-3: 63.4%/27.5%/9.1% vs CLIF's grades 1-3: 25.8%/56.3%/17.9%). COSSH-ACLF II score showed the highest predictive values for 28-day/90-day LT-free mortality in both cirrhotic and all ACLF patients with various aetiologies, outperforming the CLIF-C ACLF and other scores. The comparable performance of China-CLIFs (renamed from COSSH-ACLFs) was validated in three non-Asian cohorts.

Conclusions: This study evaluated the broader applicability of the China-CLIF framework across diverse aetiologies and varying severity levels of ACLF. These findings may provide a valuable foundation for harmonising ACLF diagnostic and prognostic system.

Keywords: HEPATITIS B; LIVER CIRRHOSIS; LIVER FAILURE.

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Conflict of interest statement

Competing interests: None of the authors have competing financial interests to declare.

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