{
  "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.",
  "authors": [
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Jinjin Luo"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Meiqian Hu"
    },
    {
      "affiliations": [
        "Department of Infectious Diseases, The First Affiliated Hospital of Suzhou University, Suzhou, Jiangsu, China"
      ],
      "name": "Tingting Feng"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China",
        "Department of Infectious Diseases, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China"
      ],
      "name": "Liyuan Zhang"
    },
    {
      "affiliations": [
        "Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, Hunan, China"
      ],
      "name": "Yan Huang"
    },
    {
      "affiliations": [
        "Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China"
      ],
      "name": "Yuxian Huang"
    },
    {
      "affiliations": [
        "Department of Infectious Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China"
      ],
      "name": "Feng Ye"
    },
    {
      "affiliations": [
        "Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China"
      ],
      "name": "Jiang Li"
    },
    {
      "affiliations": [
        "European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain"
      ],
      "name": "Ferran Aguilar"
    },
    {
      "affiliations": [
        "European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain"
      ],
      "name": "Cristina Sánchez-Garrido"
    },
    {
      "affiliations": [
        "European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain"
      ],
      "name": "Eva Usón-Raposo"
    },
    {
      "affiliations": [
        "Senior Department of Hepatology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China"
      ],
      "name": "Bing Zhu"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Qian Zhou"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Xi Liang"
    },
    {
      "affiliations": [
        "Department of Gastroenterology, Zhejiang Provincial People’s Hospital, People’s Hospital Affiliated of Hangzhou Medical College, Hangzhou, Zhejiang, China"
      ],
      "name": "Jiaqi Li"
    },
    {
      "affiliations": [
        "Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Peng Li"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Jiaojiao Xin"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Dongyan Shi"
    },
    {
      "affiliations": [
        "Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China"
      ],
      "name": "Jianming Zheng"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Huafen Zhang"
    },
    {
      "affiliations": [
        "Department of Infectious Diseases, Union Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, Hubei, China"
      ],
      "name": "Baoju Wang"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Wei Qiang"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Heng Yao"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Xingping Zhou"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Jiaxian Chen"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Wen Hu"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Bingqi Li"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Shiwen Ma"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Xiao Wu"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Xiao Li"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Yuheng Kong"
    },
    {
      "affiliations": [
        "Wenzhou Medical University Renji College, Wenzhou, Zhejiang, China"
      ],
      "name": "Feiyang Sun"
    },
    {
      "affiliations": [
        "Department of Bioengineering, Imperial College London, London, UK"
      ],
      "name": "Xi Chen"
    },
    {
      "affiliations": [
        "International Health Care Community, Pacific Care Home, Hangzhou, Zhejiang, China"
      ],
      "name": "Tianzhou Wu"
    },
    {
      "affiliations": [
        "Department of Gastroenterology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China"
      ],
      "name": "Lingling Yang"
    },
    {
      "affiliations": [
        "Department of Endocrinology and Metabolic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Suwan Sun"
    },
    {
      "affiliations": [
        "Department of Gastroenterology, Zhejiang Provincial People’s Hospital, People’s Hospital Affiliated of Hangzhou Medical College, Hangzhou, Zhejiang, China"
      ],
      "name": "Beibei Guo"
    },
    {
      "affiliations": [
        "Department of Respiratory Disease, Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Lulu He"
    },
    {
      "affiliations": [
        "Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China"
      ],
      "name": "Jinjun Chen"
    },
    {
      "affiliations": [
        "Senior Department of Hepatology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China"
      ],
      "name": "Shaojie Xin"
    },
    {
      "affiliations": [
        "Department of Big Data in Health Science, School of Public Health and the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Xue Li"
    },
    {
      "affiliations": [
        "Department of Infectious Diseases, Taizhou Hospital of Zhejiang Province, Linhai, Zhejiang, China"
      ],
      "name": "Huazhong Chen"
    },
    {
      "affiliations": [
        "European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain",
        "Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy"
      ],
      "name": "Paolo Angeli"
    },
    {
      "affiliations": [
        "European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain",
        "Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London, UK"
      ],
      "name": "Rajiv Jalan"
    },
    {
      "affiliations": [
        "Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China"
      ],
      "name": "Bingliang Lin"
    },
    {
      "affiliations": [
        "Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Fourth Department of Liver Disease, Beijing Youan Hospital, Capital Medical University, Beijing, China"
      ],
      "name": "Yu Chen"
    },
    {
      "affiliations": [
        "Senior Department of Hepatology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China"
      ],
      "name": "Shaoli You"
    },
    {
      "affiliations": [
        "Institute of Pharmaceutical Biotechnology and the First Affiliated Hospital Department of Radiation Oncology, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China",
        "Joint Institute for Genetics and Genome Medicine between Zhejiang University and University of Toronto, Zhejiang University, Hangzhou, Zhejiang, China"
      ],
      "name": "Xin Chen"
    },
    {
      "affiliations": [
        "Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil"
      ],
      "name": "Alberto Queiroz Farias"
    },
    {
      "affiliations": [
        "European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain",
        "Department of Internal Medicine B, University of Münster, Munster, Germany"
      ],
      "name": "Jonel Trebicka"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Jing Jiang"
    },
    {
      "affiliations": [
        "European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain",
        "Institut National de la Santé et de la Recherche Médicale, Université Paris Cité, Centre de Recherche sur l’Inflammation, Paris, France",
        "Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Service d’Hépatologie, Clichy, France"
      ],
      "name": "Richard Moreau"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China"
      ],
      "name": "Jun Li"
    },
    {
      "affiliations": [
        "State Key Laboratory for Diagnosis and Treatment of Infectious Diseases, National Clinical Research Center for Infectious Diseases, National Medical Center for Infectious Diseases, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China",
        "Department of Infectious Diseases, The First Affiliated Hospital of Suzhou University, Suzhou, Jiangsu, China",
        "Department of Infectious Diseases, The Second Affiliated Hospital of Hainan Medical University, Haikou, Hainan, China",
        "Department of Infectious Diseases, Hunan Key Laboratory of Viral Hepatitis, Xiangya Hospital, Central South University, Changsha, Hunan, China",
        "Department of Infectious Diseases, Huashan Hospital, Fudan University, Shanghai, China",
        "Department of Infectious Diseases, The First Affiliated Hospital of Xi’an Jiaotong University, Xi’an, Shaanxi, China",
        "Department of Infectious Diseases, The First Affiliated Hospital of Anhui Medical University, Hefei, Anhui, China",
        "European Foundation for the Study of Chronic Liver Failure (EF CLIF), Barcelona, Spain",
        "Senior Department of Hepatology, The Fifth Medical Center of Chinese PLA General Hospital, Beijing, China",
        "Department of Gastroenterology, Zhejiang Provincial People’s Hospital, People’s Hospital Affiliated of Hangzhou Medical College, Hangzhou, Zhejiang, China",
        "Department of Gastroenterology, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China",
        "Department of Infectious Diseases, Union Hospital, Tongji Medical college, Huazhong University of Science and Technology, Wuhan, Hubei, China",
        "Wenzhou Medical University Renji College, Wenzhou, Zhejiang, China",
        "Department of Bioengineering, Imperial College London, London, UK",
        "International Health Care Community, Pacific Care Home, Hangzhou, Zhejiang, China",
        "Department of Gastroenterology, The Second Affiliated Hospital of Nanchang University, Nanchang, Jiangxi, China",
        "Department of Endocrinology and Metabolic Disease, The First Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China",
        "Department of Respiratory Disease, Sir Run Run Shaw Hospital Affiliated to Zhejiang University School of Medicine, Hangzhou, Zhejiang, China",
        "Hepatology Unit, Department of Infectious Diseases, Nanfang Hospital, Southern Medical University, Guangzhou, Guangdong, China",
        "Department of Big Data in Health Science, School of Public Health and the Second Affiliated Hospital, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China",
        "Department of Infectious Diseases, Taizhou Hospital of Zhejiang Province, Linhai, Zhejiang, China",
        "Unit of Internal Medicine and Hepatology, Department of Medicine, University of Padova, Padova, Italy",
        "Liver Failure Group, Institute for Liver Disease Health, University College London, Royal Free Hospital, London, UK",
        "Department of Infectious Diseases, The Third Affiliated Hospital of Sun Yat-sen University, Guangzhou, Guangdong, China",
        "Beijing Municipal Key Laboratory of Liver Failure and Artificial Liver Treatment Research, Fourth Department of Liver Disease, Beijing Youan Hospital, Capital Medical University, Beijing, China",
        "Institute of Pharmaceutical Biotechnology and the First Affiliated Hospital Department of Radiation Oncology, Zhejiang University School of Medicine, Hangzhou, Zhejiang, China",
        "Joint Institute for Genetics and Genome Medicine between Zhejiang University and University of Toronto, Zhejiang University, Hangzhou, Zhejiang, China",
        "Department of Gastroenterology, Hospital das Clínicas, University of São Paulo School of Medicine, São Paulo, Brazil",
        "Department of Internal Medicine B, University of Münster, Munster, Germany",
        "Institut National de la Santé et de la Recherche Médicale, Université Paris Cité, Centre de Recherche sur l’Inflammation, Paris, France",
        "Assistance Publique-Hôpitaux de Paris, Hôpital Beaujon, Service d’Hépatologie, Clichy, France"
      ],
      "name": "The CANONIC, PREDICT, ACLARA Study Group"
    },
    {
      "affiliations": [],
      "name": "Chinese Group on the Study of Severe Hepatitis B (COSSH)"
    }
  ],
  "title": "Performance of the China-CLIF framework in acute-on-chronic liver failure: a multicohort study across all aetiologies",
  "uid": "a1c61dc0-e71a-5573-98e4-09ec1a61daac"
}