Determinants of outcome among patients with acute liver failure listed for liver transplantation in the United States

Abstract

BACKGROUND & AIMS Analyses of outcomes after acute liver failure (ALF) have typically included all ALF patients regardless of whether they were listed for liver transplantation (LT). We hypothesized that limiting analysis to listed patients might provide novel insights into factors associated with outcome, focusing attention on disease evolution after listing. METHODS Listed adult ALF patients enrolled in the US Acute Liver Failure Study Group registry between 2000 and 2013 were analyzed to determine baseline factors associated with 21-day outcomes after listing. RESULTS We classified 617 patients (36% of overall ALF group) by 3-week outcome after study admission: 117 survived spontaneously (without LT, SS), 108 died without LT, and 392 underwent LT. Only 22% of acetaminophen (APAP) ALF patients were listed; however, this group of 173 patients demonstrated greater illness severity: higher coma grades, and more patients required ventilator, vasopressor or renal replacement therapy support. Only 62/173 (36%) of APAP patients received a graft, versus 66% for drug-induced liver injury patients, 86% for autoimmune and 71% for hepatitis B-related ALF. APAP patients were more likely to die than non-APAP patients (24% vs 17%), and the median time to death was sooner (2 vs 4.5 days). Despite greater severity of illness, the listed APAP group still had a SS rate of 40% vs. 11% for non-APAP causes (p < 0.001). CONCLUSIONS APAP outcomes evolve rapidly, mainly to SS or death. Patients with APAP ALF listed for LT had the highest death rate of any etiology, while more slowly evolving etiologies yielded higher LT rates, and consequently, fewer deaths. Decisions to list and transplant must be made early in all ALF patients, particularly in those with APAP ALF.

Acute Liver Failure, Etiology, and Outcome: An Experience in a Referral Liver Transplant Center

“…The patient outcomes for ALF in the present study were good with 46.7% survival, and a transplantation rate of 28.9%, comparable with the results reported from other studies (11,26). We also had a good post-transplant survival rate of 84.6% for 1 year.…”

“…Median of the time to event was shorter in patients who did not survive, emphasizing the need for more rapid action in patients with more severe disease. The median time to transplantation was 9 days in our study, which was considerably longer compared to similar reports (11,17).…”

“…Among different etiologies, ALF resulting from acetaminophen overdose has been found to have a more severe clinical condition with higher coma grades and higher rate of mortality in patients listed for liver transplantation (11). Acetaminophen overdose is the leading cause of ALF in the United States and has remained the dominant etiology over time (12,13).…”

Acetaminophen (APAP) hepatotoxicity—Isn’t it time for APAP to go away?

“…In the ALFSG experience, virtually all APAP patients reached an end point by 4 days following admission to study, while DILI patients continued to die or receive liver grafts over the ensuing 7-10 days (Figure 3). 41 Overall, 36% of ALF patients were listed for transplantation, only 22% of those with APAP ALF vs. 56% of the non-APAP ALF group. While this might be thought to be related to better outcomes with APAP, the listed APAP patients were actually sicker in terms of clinical and biochemical features.…”

Drug idiosyncrasy due to pirfenidone presenting as acute liver failure: Case report and mini‐review of the literature

“…LT is the only definitive treatment for those with poor prognosis 8. Of the 95 patients with DILI‐ALF listed for transplant between 2000 and 2013 in the United States, 22.1% (n = 21) died, 11.5% (n = 11) survived, and 66.3% (n = 63) were transplanted, with a posttransplant survival rate of 92.1% at week 3 25. Outcomes depend on the extent of injury, the number of organ failures at admission, quality of intensive care, and availability of salvage therapies.…”