Sundaram, V;
Jalan, R;
Wu, T;
Volk, ML;
Asrani, SK;
Klein, AS;
Wong, RJ;
(2019)
Factors Associated with Survival of Patients With Severe Acute on Chronic Liver Failure Before and After Liver Transplantation.
Gastroenterology
, 156
(5)
1381-1391.e3.
10.1053/j.gastro.2018.12.007.
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Abstract
BACKGROUND & AIMS: Liver transplantation for patients with acute on chronic liver failure with 3 or more failing organs (ACLF-3) is controversial. We compared liver waitlist mortality or removal according to model for end-stage liver disease (MELD) score vs ACLF category. We also studied factors associated with reduced odds of survival for 1 year after liver transplantation in patients with ACLF-3. METHODS: We analyzed data from the United Network for Organ Sharing from 2005 through 2016. We identified patients who were on the waitlist (100,594) and those who received liver transplants (50,552). Patients with ACLF were identified based on the EASL-CLIF criteria. Outcomes were evaluated with competing risks regression, Kaplan-Meier analysis, and Cox proportional hazards regression. RESULTS: Patients with ACLF-3 were more likely to die or be removed from the waitlist, regardless of MELD-Na score, compared to the other ACLF groups; the proportion was greatest for patients with an ACLF-3 score and MELD-Na score below 25 (43.8% at 28 days). Mechanical ventilation at liver transplantation (hazard ratio [HR], 1.49; 95% CI, 1.22-1.84), donor risk index above 1.7 (HR, 1.22; 95% CI, 1.09-1.35), and liver transplantation within 30 days of listing (HR, 0.89; 95% CI, 0.81-0.98) were independently associated with survival for 1 year after liver transplantation CONCLUSIONS: In an analysis of data from the United Network for Organ Sharing registry, we found high mortality among patients with ACLF-3 on the liver transplant waitlist-even among those with lower MELD-Na scores. So, certain patients with ACLF-3 have poor outcomes regardless of MELD-Na score. Liver transplantation increases odds of survival for these patients, particularly if performed within 30 days of placement on the waitlist. Mechanical ventilation at liver transplantation and use of marginal organs were associated with increased risk of death.
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