Abstract / Summary
Background The impact of liver transplantation (LT) on mortality among patients with advanced cirrhosis who have two organ failures (acute-on-chronic liver failure-2 [ACLF-2]) or ≥ three organ failures (ACLF-3) is unclear. METHODS Adults with decompensated cirrhosis with or without ACLF (grades 1–3), undergoing LT at 63 liver transplant centers worldwide were prospectively enrolled between 2021 and 2023 and followed for one year. Patients with ACLF-2 or ACLF-3 who were declined for LT were also prospectively followed for one year. RESULTS Among the 144 patients declined for LT, 73% of those included with ACLF-2 and 88% of those with ACLF-3 died within 1 year. Of the 612 transplanted patients, 2% were re-transplanted and 12% died during the year. According to ACLF status at LT, the case-fatality rate without re-transplantation was 21% with ACLF-3 (42% when patients had five or six organ failures), 10.5% with ACLF-2, 10% with ACLF-1 (one organ failure), and 9% without ACLF. During the post-LT period, ACLF-3 patients experienced longer intensive care stay but similar ward stay, readmission rate and requirement for long-term renal replacement therapy. In time-to-event multivariable analyses, variables that were associated with higher post-LT mortality were being transplanted in Asia (vs. Europe or North America) or having ACLF-3 at LT (vs. no ACLF). The risk of dying after LT was similar in Asia vs. Latin America or with ACLF-2 vs. no ACLF. CONCLUSIONS Patients with severe ACLF who underwent LT showed markedly better survival outcomes than those who were declined. Patients with five or six organ failures had high risk of post-LT death cautioning against routine LT in this population. Clinical trial number ClinicalTrials.gov number, NCT04613921