CLIF-OF >9 predicts poor outcome in patients with Amanita phalloides poisoning

  • Yongzhuang Ye
    Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
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  • Zhenning Liu
    Corresponding author at: Department of Emergency Medicine, Shengjing Hospital of China Medical University, No. 36, Sanhao Street, Heping District, Shenyang 110004, People's Republic of China.
    Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
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  • Min Zhao
    Department of Emergency Medicine, Shengjing Hospital of China Medical University, Shenyang, Liaoning, People's Republic of China
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Published:January 16, 2020DOI:



      Amanita phalloides poisoning with high mortality is rare but serious. The aim of this study is to identify the risk indicators of death in patients with Amanita phalloides poisoning and a good score tool to predict prognosis.


      In this respective study (1/2009–12/2018), the patients (n = 105) with Amanita phalloides poisoning from two hospitals of China Medical University who met the inclusion/exclusion criteria were included. The laboratory markers and the clinical scoring systems including Child–Turcotte–Pugh (CTP), Sequential organ failure assessment (SOFA), Liver injury and Failure evaluation (LiFe), Chronic liver failure-organ failure score system (CLIF-OF), King's College criteria (KCH criteria), Model for end-stage liver disease (MELD) and Platelet-bilirubin-albumin (PALBI) within 24 h of admission to the two hospitals were analyzed and area under the curve (AUC) analyses were also performed regarding the prediction of death.


      The data analysis indicated that high international normalized ratio (INR) (>3.6, AUC = 0.941) and plasma ammonia (>95.1 μmol/L, AUC = 0.805) were closely associated with mortality after multivariate logistic regression. CLIF-OF (>9) within 24 h with really good diagnostic accuracy (>90%) significantly outperformed the other scores in predicting mortality.


      CLIF-OF (>9) within 24 h of admission is considered as a satisfactory and practical tool to predict a poor outcome of Amanita phalloides poisoning.


      ALF (acute liver failure), ALT (alanine transaminase), APTT (activated partial thromboplastin time), AST (aspartate aminotransferase), AUC (area under the curve), BILD (conjugated bilirubin), BILT (total bilirubin), BUN (blood urea nitrogen), CI (confidence interval), CLIF-OF (Chronic Liver Failure-Organ Failure), CTP (Child-Turcotte-Pugh), HE (hepatic encephalopathy), INR (international normalized ratio), KCH (King's College Hospital criteria), LiFe (Liver injury and Failure evaluation), MELD (Model of End Stage Liver Disease), NLR (neutrophil-lymphocyte ratio), NPV (negative predictive value), PA (predictive accuracy), PALBI (Platelet-albumin-bilirubin), PPV (positive predictive value), ROC curve (receiver operating characteristic curve), SOFA (Sequential Organ Failure Assessment), UNBIL (unconjugated bilirubin), WBC (white blood cell)


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        • Bonacini M.
        • Shetler K.
        • Yu I.
        • et al.
        Features of patients with severe hepatitis due to mushroom poisoning and factors associated with outcome.
        Clin Gastroenterol Hepatol. 2017; 15: 776-779
        • Mas A.
        Mushrooms, amatoxins and the liver.
        J Hepatol. 2005; 42: 166-169
        • Trabulus S.
        • Altiparmak M.R.
        Clinical features and outcome of patients with amatoxin-containing mushroom poisoning.
        Clin Toxicol (Phila). 2011; 49: 303-310
        • Jaeger A.
        • Jehl F.
        • Flesch F.
        • et al.
        Kinetics of amatoxins in human poisoning: therapeutic implications.
        J Toxicol Clin Toxicol. 1993; 31: 63-80
        • Escudie L.
        • Francoz C.
        • Vinel J.P.
        • et al.
        Amanita phalloides poisoning: reassessment of prognostic factors and indications for emergency liver transplantation.
        J Hepatol. 2007; 46: 466-473
        • Enjalbert F.
        • Rapior S.
        • Nouguier-Soule J.
        • et al.
        Treatment of amatoxin poisoning: 20-year retrospective analysis.
        J Toxicol Clin Toxicol. 2002; 40: 715-757
        • Yang Z.L.
        Flora fungorum sinicorum. Vol. 27. Amanitaceae.
        Science Press, Beijing2005
        • Yang Z.L.
        Atlas of the Chinese species of Amanitaceae.
        Science Press, Beijing2015
        • Aithal G.P.
        • Watkins P.B.
        • Andrade R.J.
        • et al.
        Case definition and phenotype standardization in drug-induced liver injury.
        Clin Pharmacol Ther. 2011; 89: 806-815
        • Pugh R.N.
        • Murray-Lyon I.M.
        • Dawson J.L.
        • et al.
        Transection of the oesophagus for bleeding oesophageal varices.
        Br J Surg. 1973; 60: 646-649
        • Gyawali B.
        • Ramakrishna K.
        • Dhamoon A.S.
        Sepsis: the evolution in definition, pathophysiology, and management.
        SAGE Open Med. 2019; 7 (2050312119835043)
        • Edmark C.
        • McPhail M.J.W.
        • Bell M.
        • et al.
        LiFe: a liver injury score to predict outcome in critically ill patients.
        Intensive Care Med. 2016; 42: 361-369
        • Jalan R.
        • Saliba F.
        • Pavesi M.
        • et al.
        Development and validation of a prognostic score to predict mortality in patients with acute-on-chronic liver failure.
        J Hepatol. 2014; 61: 1038-1047
        • O’Grady J.G.
        • Alexander G.J.
        • Hayllar K.M.
        • et al.
        Early indicators of prognosis in fulminant hepatic failure.
        Gastroenterology. 1989; 97: 439-445
        • Malinchoc M.
        • Kamath P.S.
        • Gordon F.D.
        • et al.
        A model to predict poor survival in patients undergoing transjugular intrahepatic portosystemic shunts.
        Hepatology. 2000; 31: 864-871
        • Hansmann J.
        • Evers M.J.
        • Bui J.T.
        • et al.
        Albumin-bilirubin and platelet-albumin-bilirubin grades accurately predict overall survival in high-risk patients undergoing conventional transarterial chemoembolization for hepatocellular carcinoma.
        J Vasc Interv Radiol. 2017; 28: 1224-31 e2
        • Fantozzi R.
        • Ledda F.
        • Caramelli L.
        • et al.
        Clinical findings and follow-up evaluation of an outbreak of mushroom poisoning–survey of Amanita phalloides poisoning.
        Klin Wochenschr. 1986; 64: 38-43
        • Kim T.
        • Lee D.
        • Lee J.H.
        • et al.
        Predictors of poor outcomes in patients with wild mushroom-induced acute liver injury.
        World J Gastroenterol. 2017; 23: 1262-1267
        • Ozer J.
        • Ratner M.
        • Shaw M.
        • et al.
        The current state of serum biomarkers of hepatotoxicity.
        Toxicology. 2008; 245: 194-205
        • Contreras-Zentella M.L.
        • Hernandez-Munoz R.
        Is liver enzyme release really associated with cell necrosis induced by oxidant stress?.
        Oxid Med Cell Longev. 2016; 2016: 3529149
        • Ganzert M.
        • Felgenhauer N.
        • Zilker T.
        Indication of liver transplantation following amatoxin intoxication.
        J Hepatol. 2005; 42: 202-209
        • McPhail M.J.
        • Farne H.
        • Senvar N.
        • et al.
        Ability of King’s college criteria and model for end-stage liver disease scores to predict mortality of patients with acute liver failure: a meta-analysis.
        Clin Gastroenterol Hepatol. 2016; 14 ([quiz e43-e45]): 516-25 e5
        • Manka P.
        • Bechmann L.P.
        • Tacke F.
        • et al.
        Serum sodium based modification of the MELD does not improve prediction of outcome in acute liver failure.
        BMC Gastroenterol. 2013; 13: 58
        • Rodrigues-Filho E.M.
        • Fernandes R.
        • Garcez A.
        SOFA in the first 24 hours as an outcome predictor of acute liver failure.
        Rev Bras Ter Intensiva. 2018; 30: 64-70
        • Yao S.
        • Jiang X.
        • Sun C.
        • et al.
        External validation and improvement of LiFe score as a prediction tool in critically ill cirrhosis patients.
        Hepatol Res. 2018; 48: 905-913
        • Shi Y.
        • Shu Z.
        • Sun W.
        • et al.
        Risk stratification of decompensated cirrhosis patients by chronic liver failure consortium scores: classification and regression tree analysis.
        Hepatol Res. 2017; 47: 328-337
        • Zhao H.
        • Gu X.
        • Zhao R.
        • et al.
        Evaluation of prognostic scoring systems in liver cirrhosis patients with bloodstream infection.
        Medicine (Baltimore). 2017; 96e8844