Abstract
Background
The impact of liver transplantation (LT) on mortality among patients with advanced cirrhosis who have two organ failures (acute-on-chronic liver failure-2 [ACLF-2]) or ≥ three organ failures (ACLF-3) is unclear.Methods
Adults with decompensated cirrhosis with or without ACLF (grades 1-3), undergoing LT at 63 liver transplant centers worldwide were prospectively enrolled between 2021 and 2023 and followed for one year. Patients with ACLF-2 or ACLF-3 who were declined for LT were also prospectively followed for one year.Results
Among the 144 patients declined for LT, 73% of those included with ACLF-2 and 88% of those with ACLF-3 died within 1 year. Of the 612 transplanted patients, 2% were re-transplanted and 12% died during the year. According to ACLF status at LT, the case-fatality rate without re-transplantation was 21% with ACLF-3 (42% when patients had five or six organ failures), 10.5% with ACLF-2, 10% with ACLF-1 (one organ failure), and 9% without ACLF. During the post-LT period, ACLF-3 patients experienced longer intensive care stay but similar ward stay, readmission rate and requirement for long-term renal replacement therapy. In time-to-event multivariable analyses, variables that were associated with higher post-LT mortality were being transplanted in Asia (vs. Europe or North America) or having ACLF-3 at LT (vs. no ACLF). The risk of dying after LT was similar in Asia vs. Latin America or with ACLF-2 vs. no ACLF.Conclusions
Patients with severe ACLF who underwent LT showed markedly better survival outcomes than those who were declined. Patients with five or six organ failures had high risk of post-LT death cautioning against routine LT in this population.Clinical trial number
ClinicalTrials.gov number, NCT04613921.