Systematic review with meta‐analysis: liver transplant provides survival benefit in patients with acute on chronic liver failure

Abstract

SummaryBackgroundData on liver transplantation (LT) in acute on chronic liver failure (ACLF) are scanty.AimTo perform meta‐analysis on outcomes after LT for ACLF compared with ACLF patients not receiving LT or with LT recipients for indications other than ACLF.MethodsWe pooled data from 12 studies on LT outcomes among ACLF patients.ResultsAmong nine studies, 22 238 LT recipients for ACLF vs 30 791 for non‐ACLF were younger by 1.1 years, less males (64% vs 66.4%), and higher model for end‐stage disease score by 14.5 (14.4‐14.6), P < 0.01 for all. Post‐transplant patient survival at 30 day, 90 day, 6 months, 1 year and 5 years was lower in ACLF: 96.2% vs 98.1%, 92.6% vs 96.2%, 89.9% vs 94.4%, 86.0% vs 91.9%, 66.9% vs 80.7% respectively, P < 0.01 for all. ACLF patients stayed longer in hospital and ICU by 5.7 and 10.5 days respectively, P < 0.001, with similar post‐transplant complications [74.4% vs 55.5%, P = 0.12]. Among three studies, 441 LT recipients for ACLF vs 301 ACLF patients not selected for LT had better 30 day and 1 year survival: 95.2% vs 60% and 85.3% vs 28.2% respectively, P < 0.001. Outcomes were worse in ACLF‐3 and better for ACLF‐1 and ACLF‐2 patients at the time of LT.ConclusionIn this pooled analysis with a large sample size across the globe, LT for select patients with ACLF provided survival benefit. However, larger prospective studies are needed to further refine selection criteria, especially for ACLF‐3 patients as basis for improving outcomes and optimal utilisation of scarce donor pool.

Dynamic Prognostication in Transplant Candidates with Acute-on-Chronic Liver Failure

“…Irrespective of whether the patients received the transplant, 3-month survival after admission was critical in determining long-term outcome. Fourth, although multiple factors (particularly those at day 14) were associated with survival in univariable analysis, in multivariable analysis, AARC score at day 14 was associated with poor survival in the nontransplant group and all patients with ACLF.…”

“…Ideally, patients with ACLF whose livers have limited capacity for self-recovery should be transplanted in a timely manner to maximize transplant efficiency. In a pooled meta-analysis study with a large sample size from across the globe, liver transplant provided more survival benefit in patients with ACLF in earlier stages than in later stages [14,15]. In Western societies where deceased donors were the main organ source, allocation policies may not favor patients with ACLF and they are at a mortality disadvantage in the MELD-based system [16,17].…”

“…Among 18 dynamic variables (D-1, D-7, and D- 14), nine were found to be nonsignificant at all three time points in univariable Cox analysis. Figure 3 shows the trend of dynamic prognostication.…”

Organ allocation for patients with acute-on-chronic liver failure: Time to look beyond MELD-sodium?

“…There is now a large body of published work that individually and cumulatively provide clear evidence of transplant benefit for patients with ACLF with 5-year survival rates of about 65-70% even in those with ACLF-3. 13,15 Based on the arguments presented, a pilot programme has been initiated in the UK where patients with ACLF-2 and 3 will be listed for transplantation separately and organs will be allocated to these patients as a priority immediately after the patients listed with acute liver failure. The accumulated data would suggest that similar pilots should be explored in other countries.…”

Long‐term outcomes after liver transplantation for ACLF – Don’t forget quality of life!

“…While these results are poorer than those of patients transplanted without ACLF or those with grade 1 or 2 ACLF, it must be kept in mind that spontaneous 3‐month survival is around 20% in this group of patients. Although short‐term individual benefit of LT in these patients is clear, these benefits must be balanced with a lower post‐LT survival with respect to other indications of LT 4 . In addition, when it comes to long‐term outcomes of patients transplanted because of ACLF, it is important to highlight that information in this respect is scarce.…”