Research highlights ‘serious unmet need’ for LT in severe acute-on-chronic liver failure
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Key takeaways:
- At 3 months, 28% of waitlisted patients with acute-on-chronic liver failure grades 2 and 3 died or were delisted.
- Among those not waitlisted for liver transplantation, 85% died.
Interim results from a global, multicenter study demonstrated the benefit of liver transplantation among patients with acute-on-chronic liver failure grades 2 and 3 and suggest that current allocation systems are inadequate.
In the observational CHANCE study, Rajiv Jalan, MD, PhD, of the University College London, and colleagues used data from 66 LT centers in 21 countries to compare 1-year graft and patient survival rates following LT in patients with ACLF 2 or 3 vs. those with decompensated cirrhosis without ACLF, as well as transplant-free survival of patients not listed for LT.
The study population included 376 patients with acute-on-chronic liver failure grade 2 or 3 listed for LT (group 1), 313 with decompensated cirrhosis without ACLF (group 2) and 134 patients with ACLF 2 or 3 not listed for LT (group 3) between July 2021 and October 2023.
At baseline, Jalan noted 53% and 42% of patients in group 1 and group 3, respectively, had ACLF 2 while 47% and 58% had ACLF 3. More than half of patients in group 2 had no ACLF (65%) and 35% had ACLF 1.
Interim results at 3 months showed 28% of patients in group 1 and 16% of patients in group 2 died or were removed from the waitlist, while 68% and 79%, respectively, underwent LT. Among patients in group 3, who were not listed for LT, 85% died.
“The data confirms here that death on the waiting list of patients with ACLF grade 2 or 3 that have relatively low MELD score is nearly 50%,” Jalan said. “It suggests that these patients are disadvantaged on the current waiting list programs.”
Specifically, results demonstrated a higher risk for death at all MELD-Na score ranges among patients with ACLF 2 or 3 vs. those without (< 25: 50% vs. 12%; 25-29: 35% vs. 19%; 30-34: 22% vs. 15%; > 35: 29% vs. 17%).
Jalan also noted a “significantly higher” rate of waitlist death or delisting among patients in Latin American (40%) compared with those in North America (20%), Europe (18%) and Asia (13%), as well as “significant differences” in 3-month post-LT mortality (16%, 3%, 7% and 12%, respectively).
“Treatment of ACLF is a serious unmet need,” Jalan said. “The interim results of this study provide evidence of transplant benefit for patients with ACLF grades 2 and 3. It also illustrates the inadequacy of the current allocation criteria for this population of patients leading to an excess mortality on the transplant waiting list.”
He continued: “These results, if confirmed in the full analysis, strongly argue for increasing access to liver transplantation and a possible change in the organ allocation system with this population of patients with very severe ACLF.”
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Gustot T, et al. Excess waitlist mortality and survival benefit of liver transplantation for patients with severe acute-on-chronic liver failure: Interim results of the CHANCE study. Presented at: EASL Congress; June 5-8, 2024; Milan (hybrid).
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