Stabilisation of acute‐on‐chronic liver failure patients before liver transplantation predicts post‐transplant survival

Abstract

Acute-on-chronic liver failure predicts adverse outcome after orthotopic liver transplantation. Given the dismal prognosis without transplantation, however, our results indicate that ACLF patients can be transplanted with comparably good outcomes, in particular patients who improve under conservative therapeutic measures.

Lactate Improves Prediction of Short‐Term Mortality in Critically Ill Patients With Cirrhosis

“…Vice versa, 72% of patients with sepsis on ICU admission showed admission lactate levels >2 mmol/L. Accordingly, compared with patients with admission lactate levels within the normal range, patients with increased lactate levels on admission presented with higher heart rates and lower blood pressure as well as body temperature (3) Hepatic encephalopathy 81 (14) Surgery/intervention* 123 (22) Other 53 (9) MELD score, median (IQR) 20 (14)(15)(16)(17)(18)(19)(20)(21)(22)(23)(24)(25)(26)(27)(28)(29) Child-Pugh score, median (IQR) 9 (7-11)…”

“…Different scoring systems have been developed in order to assess prognosis in patients with cirrhosis and ACLF . Assessment of prognosis, especially in patients with cirrhosis at the ICU, is of crucial importance in order to guide therapeutic measures …”

Approaches for patients with very high MELD scores

“…Post-LT 3-month survival of recipients is about 80-90% and much higher than that anticipated if patients were not transplanted. 29,50,87,98,[115][116][117] Indeed, in the CANONIC study, patients transplanted with an ACLF grade 2 and 3 between day 3 and day 7 (n = 21) had a better 6-month survival than the non-transplanted patients (80.9 vs. 10%, p < 0.001). 29 Similarly, in our reported experience, the 73 patients transplanted with ACLF grade 3 at the time of LT had better 1-year survival than matched controls (83.9 vs. 7.9%, p < 0.0001).…”

“…This is in line with a recent report that identified severe acute respiratory distress syndrome as an independent factor associated with post-transplant mortality. 118 Improvement or stabilization in OFs in the immediate pretransplant period has been associated with favourable post-LT outcomes in patients with ACLF, suggesting that the evolution of OFs should at least be controlled, if not improved, before considering an LT. 98,115 Another important point to consider is the timeframe of LT. In most studies reporting favourable post-LT outcomes in these severely ill patients, an "early" LT has been performed (time between placement on the waiting list and LT ranging from 3-9 days).…”

“…This also leads to a high rate of complications observed in this population, who therefore require attentive screening for complications, particularly of an infectious nature. 87,98,115,117 The current knowledge suggests that transplant outcomes in selected patients with ACLF could be favourable, even in patients with multiorgan failure at the time of LT. However, in order to optimize post-LT outcomes, LT should be performed in a timely manner after admission, within a window of improvement or at least stabilization of OFs.…”