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‘Transplant window’ determines high success in severe liver failure

Patients with acute-on-chronic liver failure grade 3 had similar rates of 1-year survival after liver transplantation compared with patients with a lower grade of liver failure, according to a recently published study. Researchers attributed this to quicker decision-making and better post-transplant management.

“These good survival results are associated with an increased post-LT hospital stay and high rate of complications,” Florent Artru, MD, from the Hôpital Claude Huriez, Lille, France, and colleagues wrote. “However, to obtain these good results a short decision-making process is needed because of the short ‘transplantation window’ suggesting that patients with [acute-on-chronic liver failure grade 3] must be rapidly referred to a specific liver ICU.”

The study included 73 patients with acute-on-chronic liver failure grade 3 (ACLF-3) who received liver transplant between Jan. 1, 2008, and Dec. 31, 2014. Median time between placement on the waitlist and transplantation was 8 days (range, 3-24 days).

All patients with ACLF-3 developed complications posttransplant and 80.8% had bacterial infections. At 1-year posttransplant, 11 patients died and overall survival was 83.6% (95% CI, 75-92). Factors associated with 1-year mortality included age 57 years or older (HR = 0.19; 95% CI, 0.04-0.86) and Simplified Acute Physiology II scores (HR = 1.05; 95% CI, 1.01-1.1).

They 1-year survival rates were not significantly different when comparing patients with ACLF-3 and those cirrhosis but not ACLF (90%; 95% CI, 86.5–93.4), patients with ACLF-1 (82.3%; 95% CI, 80.6-91.8) and patients with ACLF-2 (86.2%; 95% CI, 75.1-92.1).

“The good results in survival in our most severely ill patients (ACLF-3) are in contrast with past studies showing increased mortality in patients transplanted with severe cirrhosis,” Artru and colleagues wrote. According to the researchers, prior studies were performed before the use of allocations based on MELD scores, enabling a shorter waiting time in patients with severe decompensated cirrhosis, and the prognosis of patients with severe liver decompensation has improved over the last few years in the ICU. Additionally, immunosuppressive regimens, infection treatment, overall ventilation and other contributing factors in post-transplant management have improved during this same time period.

Predictive futility scores

The researchers also assessed the predictive value of the Preallocation Survival Outcomes Following Liver Transplantation (P-SOFT), Balance of Risk (BAR) and University of California, Los Angeles (UCLA) Futility Risk scores, and compared them with the outcomes of the study.

The median P-SOFT score was 30 (range, 27-33) and the median BAR score was 19 (range, 16-21), which would predict 1-year survival rates of 75% and approximately 60%, respectively, compared with the outcome of 83.6%. The median UCLA score, however, was 20 (range, 18-23) and would predict a 1-year survival rate of 89%.

“In a context of worldwide organ scarcities, numerous studies have tried to identify the predictive factors of early post-LT mortality to avoid futile LT,” Artru and colleagues wrote. “Among the three scores tested in our study, the BAR and P-SOFT seemed to overestimate the risk of death compared to survival in the original papers.”

However, the researchers conclude that none of the scoring systems performed well on Harrell’s c-index and were not clinically useful in the population. “One possible explanation could be that they do not take the ‘transplantation window’ into account,” they wrote. – by Talitha Bennett

Disclosure: The researchers report no relevant financial disclosures.