Clinical stabilization of ACLF patients before orthotopic liver transplantation predicts post-transplant survival

Background:

Acute-on-chronic liver failure (ACLF) is a severe complication of liver cirrhosis associated with excess short-term mortality rates. Orthotopic liver transplantation (OLT) is a potentially life-saving therapeutic modality for ACLF patients, but selection of transplant candidates with an acceptable post-OLT outcome is difficult.

Objective:

The aim of this study was to assess the risk of OLT in patients with ACLF, and to determine parameters that predict post-OLT survival in this patient cohort.

Methods:

We retrospectively analyzed all 250 patients with liver cirrhosis who underwent their first liver transplantation between 2009 and 2014 at our institution.

Results:

Of 250 cirrhotic liver transplant recipients, 98 patients fulfilled the diagnostic criteria for ACLF in the 3-month pre-transplant period. Compared to non-ACLF patients, ACLF was associated with significantly higher short-term morbidity and mortality after OLT (90-day patient survival 96.1% non-ACLF versus 72.4% ACLF patients, p < 0.0001). Clinical improvement in the pre-transplant period, as defined by recovery of at least one previously failed organ system, was observed in 37 of 98 ACLF patients, mostly within several days after diagnosis. Most notably, clinical improvement prior to OLT was associated with excellent post-transplant survival rates that approximated non-ACLF OLT recipients. Following the 90-day post-transplant period, patient survival and long-term graft functions were comparable between ACLF and non-ACLF OLT recipients for up to five years.

Conclusions:

Given the dismal prognosis of ACLF, our results collectively indicate that ACLF patients can be transplanted with comparably good outcomes, in particular patients who improve under conservative therapeutic measures.