LAUSR

To the Editor: We read the paper by Sersté et al. regarding the significance of acute-on-chronic liver failure (ACLF) in alcoholic hepatitis (AH) with interest. They conclude that ACLF in AH is associated with a poor outcome and that the Lille response to corticosteroids was reduced in those with prevalent ACLF. In the light of this we have interrogated the STOPAH database to determine the role of ACLF in AH. The calculation of the CLIF-OF score in STOPAH patients was limited by the absence of data relating to respiratory function. However, in the Sersté study only 4.2% of patients in the Erasme cohort had pulmonary failure, which is assumed to have been infrequent in the STOPAH cohort. For the purposes of calculating the CLIF-C ACLF score, the respiratory sub-score was therefore assumed to be 1. Based on this assumption, the CLIF-OF score, the ACLF grade and the CLIF-C ACLF score were calculable in 1,019 of 1,069 patients who were previously described in the STOPAH trial. Comparisons between groups were analysed using chi-squared (v) tests and between survival curves using Kaplan-Meier logrank tests for trends. In addition to the absence of respiratory data, the STOPAH protocol excluded patients with severe renal impairment (creatinine >500 lmol/L) and those on inotropic support, thereby not including many patients with CLIF-OF sub-scores of 3 for renal and circulatory systems. Therefore, the proportion of those recruited with ACLF was less than that seen by Sersté et al. who noted that more than 20% of patients had circulatory and/or respiratory failure in the Erasme cohort. In the STOPAH cohort, the numbers of patients with ACLF were 737 (72.3%), 152 (14.9%), 115 (11.3%) and 15 (1.5%) for grades 0, 1, 2 and 3, respectively. The median CLIF-OF score was 8 (range 6–13) and mean CLIF-C ACLF score was 41.4 (standard deviation 6.8). For the purpose of analyses, ACLF Grade 2 and 3 patients were grouped together. Overall survival rates at 28 days were 90.2%, 75.7% and 56.9%, and at 90 days were 80.3%, 65.8% and 43.8% for ACLF 0, ACLF 1 and ACLF (2+3) respectively. The area under the curve for the CLIF-C ACLF score relating to prediction of 28-day outcome was 0.793 (95% CI 0.767–0.818) and of