How to identify the need for liver transplantation in pediatric acute-on-chronic liver failure?

The objectives of the study were to evaluate the prognostic value of APASL ACLF Research Consortium—Acute-on-chronic liver failure (AARC-ACLF) score against the current prognostic models in pediatric ACLF and to assess the role of pediatric modifications of AARC-ACLF score and chronic liver failure–sequential organ failure assessment (CLIF–SOFA) score. All children between 1 and 18 years of age satisfying the APASL definition of ACLF were included in the study. All the prognostic scores were calculated retrospectively from hospital records. Outcome was assessed at days 28 and 90. Pediatric modifications of AARC-ACLF and CLIF–SOFA scores were evaluated. Acute-on-chronic liver failure was seen in 86 (13.4%) of 640 children with chronic liver disease. Twenty-five (29.8%) children died, 7 (8.3%) underwent liver transplant and the remaining 52 (61.9%) survived with their native liver. Four prognostic models (AARC-ACLF, AARC-ACLF-Pediatric, CLIF–SOFA and CLIF–SOFA-Pediatric) had an AUROC greater than 0.9 for predicting poor outcome in pediatric ACLF. AARC-ACLF and CLIF–SOFA models were superior to other prognostic scores with a cutoff score of 11 or more predicting poor outcome. Pediatric modifications of AARC-ACLF and CLIF–SOFA scores were not superior to their original scores. Children with poor outcome had rising scores at day 4, whereas the scores were falling in those with good outcome. AARC-ACLF and CLIF–SOFA models are superior to other prognostic scores in pediatric ACLF. The scores are dynamic and a patient with either of these scores ≥ 11 at admission and/or a rising score at day 4 has high likelihood of death and needs to be urgently listed for liver transplantation.