Living Donor Liver Transplantation for Acute‐on‐Chronic Liver Failure

Abstract

Acute-on-chronic liver failure (ACLF) is a syndrome characterized by acute decompensation of previously diagnosed or undiagnosed liver disease with organ failure(s) with high short-term mortality. This study was conducted to report the outcomes of living donor liver transplantation (LDLT) in ACLF and assess the survival benefit of liver transplantation (LT) in these patients. It was a retrospective study of 218 ACLF patients on the basis of European Association for the Study of the Liver (EASL)-chronic liver failure criteria from January 2014 through November 2017. Patients were considered for LDLT if there was no improvement on standard medical therapy for 5-10 days. Prior to LDLT, active sepsis was excluded/treated, and renal, circulatory, and respiratory failures were improved to the greatest extent possible. The mean age was 42.9 years, and 181 patients were male. Sepsis was the most common acute precipitating event followed by alcohol. Of the patients, 35 (16.1%), 66 (30.3%), and 117 (53.7%) were classified into ACLF grades 1, 2, and 3, respectively. Although 80% of the ACLF 1 group and 72.7% of the ACLF 2 group underwent LDLT, only 35% of the ACLF 3 group could undergo LDLT. The circulatory and respiratory failures at admission were significantly higher in the nontransplant group with poor subsequent response to standard medical therapy, exclusion from LDLT, and poor outcomes. None of the patients on high support for circulatory and respiratory failure underwent LDLT. Posttransplant survival at 1 year was comparable among different grades of ACLF (92.9%, 85.4%, and 75.6%; P = 0.15). Among patients in the ACLF 3 group, survival at 90 days was extremely poor in those who could not undergo LDLT (5.9% versus 78%; P < 0.001). In conclusion, LDLT results in good survival with acceptable post-LT morbidity in patients with ACLF. YaDav et aL.Renal 63 (28.9) Brain 39 (17.9) Circulation 48 (22.0) Respiration 39 (17.9) Organ failure at 7 days after admission Liver 177 (81.2) Coagulation 112 (51.4) Renal 50 (22.9) Brain 37 (17.0) Circulation 71 (32.6) Respiration 72 (33.0) NOTE: Data are given as n (%) and mean ± SD. Liver transpLantation, vol. 25, no. 3, 2019 YaDav et aL.

Patients With Acute on Chronic Liver Failure Grade 3 Have Greater 14‐Day Waitlist Mortality Than Status‐1a Patients

“…In the ACLF‐3 population, the absence of mechanical ventilation at the time of LT may further improve 1‐year survival probability to approximately 85% . As transplantation markedly improves survival among candidates with ACLF‐3, additional strategies should be considered in caring for this population, including LT after stabilization of organ failures or judicious use of living donor organ transplant …”

Liver Transplantation for Acute on Chronic Liver Failure

“…Gustot et al showed a survival rate of 80.9% at 6 months in patients with ACLF 2-3 as compared to 10% in similar grades of ACLF patients who could not undergo LT. The data from our centre 33 published as abstract in international liver transplant society meet 2017 shows survival rate of 80% in transplant recipients as compared to 32% in patients without transplant at 6 months. Artru et al showed survival of 80% in patients with grade 3 ACLF as compared to 7.9% in controls.…”

“…2 Table 3 shows outcome of LT for ACLF. 7,[22][23][24][25][26][27][28][29][30][31][32][33] The majority of studies have shown good outcomes and comparable survival rates in patients transplanted for non-ACLF, however, most of these studies have not included patients with higher ACLF grades (multi-OF). Patients with severe ACLF have been shown to have lower survival rates in some of these studies 30,32 as compared to patients transplanted for non-ACLF, however, even this survival rate is much better than survival of patients without transplantation.…”

Predictors and outcome of emergent Liver transplantation for patients with acute-on-chronic liver failure

“…Yet, it is very likely that very sick patients may not have been added to the LT waitlist. In a study of 218 ACLF patients, fewer patients with ACLF grade 3 re- ceived LT compared to those with ACLF grades 2 or 1 (35%, 72.7%, and 80% for ACLF grade 3, 2, and 1, respectively) [19] . Circulatory and respiratory system failures were higher in the nontransplant group and none of the patients on high support for circulatory and respiratory failure underwent LDLT [19] .…”

“…In a study of 218 ACLF patients, fewer patients with ACLF grade 3 re- ceived LT compared to those with ACLF grades 2 or 1 (35%, 72.7%, and 80% for ACLF grade 3, 2, and 1, respectively) [19] . Circulatory and respiratory system failures were higher in the nontransplant group and none of the patients on high support for circulatory and respiratory failure underwent LDLT [19] . In addition, the dropout rate from waitlists is higher for those with multiple organ failure.…”