Liver transplantation for critically ill cirrhotic patients: Stratifying utility based on pretransplant factors

Abstract

The aim of this study was to produce a prognostic model to help predict posttransplant survival in patients transplanted with grade‐3 acute‐on‐chronic liver failure (ACLF‐3). Patients with ACLF‐3 who underwent liver transplantation (LT) between 2007 and 2017 in 5 transplant centers were included (n = 152). Predictors of 1‐year mortality were retrospectively screened and tested on a single center training cohort and subsequently tested on an independent multicenter cohort composed of the 4 other centers. Four independent pretransplant risk factors were associated with 1‐year mortality after transplantation in the training cohort: age ≥53 years (P = .044), pre‐LT arterial lactate level ≥4 mml/L (P = .013), mechanical ventilation with PaO2/FiO2 ≤ 200 mm Hg (P = .026), and pre‐LT leukocyte count ≤10 G/L (P = .004). A simplified version of the model was derived by assigning 1 point to each risk factor: the transplantation for Aclf‐3 model (TAM) score. A cut‐off at 2 points distinguished a high‐risk group (score >2) from a low‐risk group (score ≤2) with 1‐year survival of 8.3% vs 83.9% respectively (P < .001). This model was subsequently validated in the independent multicenter cohort. The TAM score can help stratify posttransplant survival and identify an optimal transplantation window for patients with ACLF‐3.

Liver transplantation for acute‐on‐chronic liver failure predicts post‐transplant mortality and impaired long‐term quality of life

“…Among patients with persistent ACLF grade 3, who are at highest risk of death without LT, the identification of suitable LT candidates remains challenging. In this setting, divergent outcomes have been reported for different cohorts, likely inferred by cohort composition, patient disease dynamics as well as local rules for inclusion and exclusion of LT in participating centres 7,9 . Thus, the identification of objective and quantifiable predictors of post‐LT survival in ACLF patients is the unmet goal of an important ongoing scientific debate.…”

“…In the ACLF‐defining CANONIC and NACSELD studies, only a small minority of patients underwent LT 4,5 . Subsequent studies yielded conflicting results regarding outcomes of ACLF patients undergoing LT, 6‐9 and selection criteria for patients with regard to acceptable post‐transplant outcomes are not rigorously studied. We recently reported on the positive impact of clinical stabilization of ACLF patients prior to LT on short‐term post‐transplant survival 10 .…”

Acute-on-chronic liver failure: Definitions, pathophysiology and principles of treatment

“…74 However, as discussed in Box 2, prioritization of these patients for LT remains problematic. 71,[75][76][77][78] Conclusions ACLF is a major medical problem worldwide and its occurrence is a challenging respiration (see Fig. 1A).…”

When Is a Critically Ill Cirrhotic Patient Too Sick to Transplant? Development of Consensus Criteria by a Multidisciplinary Panel of 35 International Experts

“…The PaO2/FiO2 ratio threshold chosen by the experts was more permissive than the PaO2/FiO2 ratio < 200 mmHg that predicted a poor post-LT outcome in 2 previous studies. 29,30 Metabolic failure assessed by serum lactate levels reflects alterations of numerous metabolic functions (eg, mitochondrial dysfunction) involved in the pathogenesis of ACLF. 31 Notably again, the threshold (> 9 mmol/l) chosen by the experts to contraindicate LT is higher than the lactate levels above 4 or 5 mmol/L reported in the literature to be associated with worse posttransplant outcomes.…”

“…31 Notably again, the threshold (> 9 mmol/l) chosen by the experts to contraindicate LT is higher than the lactate levels above 4 or 5 mmol/L reported in the literature to be associated with worse posttransplant outcomes. 29,30 This perhaps reflects the experts' unease with denying sick patients a chance at LT despite indicators of poor outcomes.…”