Article Text

Download PDFPDF

Combination of CLIF-OF and CCI predicts survival in patients with cirrhosis and COVID-19
  1. Massimo Iavarone1,
  2. Roberta D'Ambrosio1,
  3. Pietro Lampertico1,2
  1. 1 Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, CRC “A. M. and A. Migliavacca” Center for Liver Disease, Milan, Italy
  2. 2 Department of Pathophysiology and Transplantation, University of Milan, Milano, Lombardia, Italy
  1. Correspondence to Dr Massimo Iavarone, Division of Gastroenterology and Hepatology, La Fondazione IRCCS Ca' Granda Ospedale Maggiore di Milano Policlinico, Milano 20122, Italy; massimo.iavarone{at}

Statistics from

Request Permissions

If you wish to reuse any or all of this article please use the link below which will take you to the Copyright Clearance Center’s RightsLink service. You will be able to get a quick price and instant permission to reuse the content in many different ways.

We read with interest the paper by Bajaj et al recently published on Gut, reporting high mortality rates in cirrhotic patients with COVID-19, as we previously showed in 50 cirrhotics enrolled in our study.1 2

Although both studies reported an increased risk of mortality following SARS-CoV-2 infection in cirrhotics, as recently confirmed by other studies in both cirrhotic and liver transplanted patients, they differ for some aspects.1–4 Bajaj and colleagues enrolled younger patients (61.0±10.6 vs 67.6±10.1 years old), mostly women (73% vs 30%), and they found similar survival in cirrhotic patients with and without COVID-19, in contrast with what we previously reported.1 2 In the North American cohort, the Charlson Comorbidity Index (CCI) was independently associated with mortality (OR 1.23, 95% CI 1.11 to 1.37, p<0.0001),1 while in our cohort CLIF-OF (OR 1.77, 95% CI 1.24 to 2.54, p=0.002) and moderate to severe lung failure (OR 1.86, 95% 1.00–3.44, p=0.048) independently predicted mortality according to a logistic regression model.5 In the present study, acute-on-chronic liver failure was defined according to the North American Consortium for the Study of End-Stage Liver Disease (NACSELD) criteria, while we referred to the CLIF consortium definition and score.

Following the publication of the paper by Bajaj et al, we also calculated the CCI score in our patient population (median 5.0), with the aim to assess its ability to predict mortality. When included in logistic regression analysis, both CLIF-OF and CCI remained the only independent predictors of overall mortality (table 1). By combining CLIF-OF and CCI scores (ie, CLIF-OF ≤9 vs >9 and CCI ≤7 vs >7), we were able to stratify cirrhotics with SARS-CoV-2 infection in three groups characterised by different mortality risks (figure 1). The likelihood of 30-day mortality progressively increased from 15% to 75% to 100% in patients without predictors (CLIF-OF ≤9 and CCI ≤7), with only one predictor (CLIF-OF >9 or CCI >7) or with both negative predictors (CLIF-OF >9 and CCI >7), respectively.

Table 1

Predictors of 30-day mortality in 50 cirrhotic patients at SARS-CoV-2 diagnosis

Figure 1

Rates of 30-day mortality in the 50 cirrhotics with SARS-CoV-2 infection, according to CLIF-OF and CCI combination.

In conclusion, the study by Bajaj and colleagues confirms high mortality rates in cirrhotic patients with COVID-19. We independently validated CCI as an important predictor of early mortality, together with CLIF-OF, and developed a new predictive model combining CLIF-OF and CCI. In our study, this model was able to stratify mortality risk in cirrhotics following SARS-CoV-2 infection, thus suggesting its potential role for personalised risk assessment in such a fragile population.

Ethics statements



  • Collaborators CirCoV study group: M Iavarone, R D’Ambrosio, A Rimondi, P Lampertico (Foundation IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, CRC “A. M. and A. Migliavacca” Center for Liver Disease, Milan, Italy); A Soria, P Bonfanti (Division of Infectious Diseases, San Gerardo Hospital, ASST Monza, University of Milan – Bicocca School of Medicine, Monza, Italy); M Triolo, S Fagiuoli (Gastroenterology 1 – Hepatology & Transplantology, ASST Papa Giovanni XXIII, Bergamo, Italy); N Pugliese, A Aghemo (Division of Internal Medicine and Hepatology, Department of Gastroenterology, Humanitas Clinical and Research Center IRCCS, Rozzano (MI), Italy); P Del Poggio (Division of Gastroenterology, Policlinico S. Marco, Zingonia, Bergamo, Italy); G Perricone, L S Belli (Hepatology and Gastroenterology Unit, Niguarda Hospital, Milan, Italy); S Massironi, M Lucà, P Invernizzi (Division of Gastroenterology and Center for Autoimmune Liver Diseases, Department of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy); A Spinetti, C Carriero (Department of Infectious and Tropical Diseases, University of Brescia and ASST Spedali Civili General Hospital, Brescia, Italy); E Buscarini, M. Pedaci (Division of Gastroenterology and Endoscopy, ASST Maggiore Hospital, Crema, Italy); M Viganò, M G Rumi (Division of Hepatology, San Giuseppe Hospital, Italy).

  • Contributors MI and PL designed the study and carried out the statistical analysis. MI and RD’A wrote the paper, and PL supervised and critically revised the paper. The data were collected by all the members of the CirCoV study group.

  • Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.

  • Competing interests MI: speaking/teaching, consultant and advisory board for Bayer, Gilead Sciences, BMS, Janssen, Ipsen, MSD, BTG-Boston Scientific, AbbVie, Guerbet, EISAI. RD’A: teaching and speaking for AbbVie, Gilead, MSD; Advisory Board for AbbVie, MSD, Research Grant from Gilead. PL: advisory board/speaker bureau for BMS, Roche, Gilead, GSK, AbbVie, MSD, Arrowhead, Alnylam, Janssen, Spring Bank, MYR, Eiger.

  • Patient and public involvement Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.

  • Provenance and peer review Not commissioned; externally peer reviewed.