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‘Downgrading’ acute-on-chronic liver failure improves post-LT survival

Improving acute-on-chronic liver failure grade from time of liver transplant listing to time of transplant enhanced posttransplant survival, especially in recipients older than 60 years.

The short-term mortality of patients with ACLF grade 3 (ACLF-3) reaches approximately 80% by day 28, according to Vinay Sundaram, MD, MSc, from Cedars-Sinai Medical Center in California, and colleagues in their study.

“In certain patients with ACLF-3, liver transplantation (LT) may be the only viable treatment. However, data regarding LT for individuals with ACLF-3 demonstrates reduced survival probability, ranging from less than 50% to 80% at 1 year,” they wrote. “Although this suggests greater likelihood of survival than supportive care without transplantation, the limited availability of donor organs necessitates judicious selection of transplant recipients.”

To assess the impact of downgrading the severity of ACLF on post-LT survival, the researchers evaluated 3,636 patients initially listed with ACLF-3 who underwent LT within 28 days from listing. At the time of LT, 75.5% remained ACLF-3 and 24.5% improved to ACLF grade 0 to grade 2.

Posttransplant survival at 1 year was higher in patients who experienced organ failure recovery that resulted in downgrading of ACLF severity compared with those who did not (88.2% vs. 82%; P < .001).

Survival rates did not differ between patients without ACLF-3 at either listing or transplantation and those who improved from ACLF-3 (90.2% vs. 88.2%). Additionally, patients listed with ACLF 0-2 and progressed to ACLF-3 at transplantation had lower survival (83.8%) compared with those listed with ACLF-3 who improved before LT (83.8% vs. 88.2%; P < .001).

Multivariate analysis adjusted for age, MELD-Na score, diabetes, and donor risk index showed that downgrading ACLF-3 correlated with a significant reduction in likelihood of posttransplant mortality at 1 year (HR = 0.65; 95% CI, 0.53-0.78). Factors associated with 1-year mortality included age 60 years or older (HR = 1.68; 95% CI, 1.31-2.18) and a donor risk index higher than 1.7 (HR = 1.22; 95% CI, 1.03-1.45).

“Given the potentially high post-LT survival, consideration for transplantation should be given to patients with three or more organ failures, with a goal of performing LT during a window of organ failure recovery,” Sundaram and colleagues concluded. “Although recovery of circulatory failure and brain failure, and removal from mechanical ventilation appear to have the greatest impact in reducing post-LT mortality, the decision to proceed with transplantation should be made on a case-by-case basis.” – by Talitha Bennett

Disclosures: Sundaram reports no relevant financial disclosures. Please see the full study for all other authors’ relevant financial disclosures.