CLIF-SOFA score and serum sodium are independentpredictors of short term

survival in decompensated cirrhosis. A prospective study

Gustavo Pereira, Flavia F. Fernandes, Vanessa L. Zenatti, CamilaM. Alcântara,

Tatiana Valdeolivas, Zulane D. Veiga, Daniela M. Mariz, João Luiz Pereira;
GastroHepatology Unit, Bonsucesso Federal Hospital, Ministry of Health, Rio de
Janeiro, Brazil.

Introduction: CLIF-SOFA score has recently been proposed asdiagnostic criteria for acute
on chronic liver failure (ACLF).Hyponatremia is a common finding in cirrhosis and
associatedwith poor prognosis. There are few studies evaluatingthe interaction between
hyponatremia and CLIF-SOFA inpredicting survival in cirrhosis. Objectives: To evaluate
theassociation between CLIF-SOFA and hyponatremia and theircapacity in predicting
survival in patients with decompensatedcirrhosis. Methods: prospective study with 145
consecutivepatients hospitalized for treatment of complications of cirrhosis.CLIF-SOFA,
presence of ACLF and hyponatremia (serumsodium<130mEq/L) were determined at
hospital admission.Transplant-free survival was evaluated at 28 days. Results:Mean age
was 57±14 years, 51% were men and cirrhosiswas due to HCV/alcohol in 62%. Ascites,
bacterial infectionsand hepatic encephalopathy were the most common complicationsat
admission, present in 72%, 48% and 40% of patients.Child and MELD scores were 9±2 and
18±8. Mean CLIF-SOFAwas 5±3 (median 5, IQR 3-7). Mean serum sodium was
133±6mEq/L and hyponatremia was diagnosed in 34 patients. Atadmission, ACLF was
diagnosed in 42 patients. Presence ofACLF was associated with male gender, alcoholic
etiology,bacterial infections, and higher leucocyte count and C-reactiveprotein values.
Patients with hyponatremia more frequently hadascites, hepatic encephalopathy and
bacterial infections, aswell as lower MAP and higher INR. Hyponatremia was
morefrequent in patients with ACLF (41 vs. 18%, p=0.004). ACLFwas diagnosed in 50%
of patients with hyponatremia (vs. 25%for patients without, p<0.001). On multivariate
analysis, CLIFSOFA(OR 1.47 95%CI 1.20-1.80) and hyponatremia (OR2.77 95%CI 1.05-
7.30), but not MELD or presence of ACLF,were independent predictors of survival. The
best cut-off pointof CLIF-SOFA in predicting mortality was 7 (sensibility 71%,specificity
82%). A high CLIF-SOFA (≥7) was not necessaryrelated to ACLF. 14 out of 42 patients
with high CLIF-SOFAdid not have ACLF. Conversely, 30% of patients with ACLFhad low
CLIF-SOFA. Presence of hyponatremia was associatedwith lower survival in patients with
high CLIF-SOFA (35% vs46%). Nevertheless, the effect of hyponatremia on survival
wasmost marked in patients with low CLIF-SOFA (69% vs. 92%,p<0.001 for all
comparisons). Conclusions: In patients withdecompensated cirrhosis, CLIF-SOFA and
serum sodium areindependently associated with prognosis. The predictive valueof CLIF-
SOFA is not related to the presence of ACLF. Hyponatremiaidentifies a subgroup of
patients with low CLIF-SOFAwith high short-term mortality.