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Factors Associated with Survival of Patients With Severe Acute on Chronic Liver Failure Before and After Liver Transplantation

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. Green open access

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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.

Type: Article
Title: Factors Associated with Survival of Patients With Severe Acute on Chronic Liver Failure Before and After Liver Transplantation
Open access status: An open access version is available from UCL Discovery
DOI: 10.1053/j.gastro.2018.12.007
Publisher version: https://doi.org/10.1053/j.gastro.2018.12.007
Language: English
Additional information: This version is the author accepted manuscript. For information on re-use, please refer to the publisher’s terms and conditions.
Keywords: DRI renal failure, MELD score, UNOS database
UCL classification: UCL
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Medical Sciences
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Medical Sciences > Div of Medicine
UCL > Provost and Vice Provost Offices > School of Life and Medical Sciences > Faculty of Medical Sciences > Div of Medicine > Inst for Liver and Digestive Hlth
URI: https://discovery.ucl.ac.uk/id/eprint/10065165
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