Models for acute on chronic liver failure development and mortality in a veterans affairs cohort

Karen Y. Xiao, Rebecca A. Hubbard, David E. Kaplan, Tamar H. Taddei, David S. Goldberg, Nadim Mahmud

Research output: Contribution to journalArticlepeer-review

5 Scopus citations


Background and purpose: The diagnosis of acute on chronic liver failure (ACLF) carries a high short-term mortality, making early identification of at-risk patients crucial. To date, there are no models that predict which patients with compensated cirrhosis will develop ACLF, and limited models exist to predict ACLF mortality. We sought to create novel risk prediction models using a large North American cohort. Methods: We performed a retrospective study of 75,922 patients with compensated cirrhosis from the Veterans Outcomes and Costs Associated with Liver Disease (VOCAL) dataset. Using 70% derivation/30% validation sets, we identified ACLF patients using the Asian Pacific Association of Liver (APASL) definition. Multivariable logistic regression was used to derive prediction models (called VOCAL-Penn) for developing ACLF at 3, 6, and 12 months. We then created prediction models for ACLF mortality at 28 and 90 days. Results: The VOCAL-Penn models for ACLF development had very good discrimination [concordance (C) statistics of 0.93, 0.92, and 0.89 at 3, 6, and 12 months, respectively] and calibration. The mortality models also had good discrimination at 28 and 90 days (C statistics 0.89 and 0.88, respectively), outperforming the Model for End-stage Liver Disease (MELD), MELD-sodium, and the APASL ACLF Research Consortium ACLF scores. Conclusion: We have developed novel tools for predicting development of ACLF in compensated cirrhosis patients, as well as for ACLF mortality. These tools may be used to proactively guide patient follow-up, prognostication, escalation of care, and transplant evaluation. Graphic abstract: Receiver operating characteristic (ROC) curves for predicting development of APASL ACLF at 3 months (a), 6 months (b), and 1 year (c) [Figure not available: see fulltext.]

Original languageEnglish (US)
Pages (from-to)587-596
Number of pages10
JournalHepatology International
Issue number4
StatePublished - Jul 1 2020


  • Acute on chronic liver failure
  • Asia pacific association of the study of the liver
  • Cirrhosis
  • Liver transplant
  • Mortality model
  • Outcomes model
  • Prediction model
  • Veterans health
  • Veterans outcomes and costs associated with liver disease

ASJC Scopus subject areas

  • Hepatology


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