Liver transplantation for patients with acute on chronic liver failure: an intention to treat analysis

Acute on chronic liver failure (ACLF), defined as acute deterioration of a patient with compensated liver disease, carries a high risk of mortality mainly due to multi-organ dysfunction. Liver transplantation (LT) is the only curative therapeutic option for these patients. The aim of this study was to determine the efficacy of LT in the treatment of patients with ACLF referred to a tertiary center. Eighty-four consecutive patients with decompensated liver cirrhosis who required intensive monitoring and/or could not be treated outside an intermediate care unit were included in this study. The mean age was 55 years (43% female, 63% male). The major underlying liver diseases were (non) alcoholic fatty liver disease (50%) and viral cirrhosis (27.4%). At admission the mean MELD, MELD Na and SOFA score were 26.6, 29.6 and 9.4. Infections, in particular SBP and pneumonia, and acute alcoholic hepatitis were the major precipitating events for decompensation. Based on an intention to treat analysis the median overall survival was 1.58 (95%CI: 0.84–2.32) months. Sixty (71.4%) patients were evaluated, but only 45 (53.6%) were actually listed for LT. Severe sepsis and acute alcoholic hepatitis were the main reasons not to consider LT. Out of the 45 patients listed for LT, only 15 could be successfully transplanted. The remaining patients died on the waiting list mainly due to sepsis and multi-organ failure leading to a waiting list mortality rate of 67%. In the post-operative period only two patients died within the first year after LT because of sepsis and graft versus host disease. The other patients had an uneventful post LT course leading to a 1- and 5-year survival rate of 85%. In multivariate analysis LT was the only positive predictive parameter, whereas sepsis, HRS 1, intubation and multi-organ failure were negative predictive factors for patient survival. Our study confirms the poor prognosis of patients with ACLF. Although more than 70% were evaluated for LT, only 18% could be successfully transplanted. Infectious complications were the main reasons for a refusal of LT and/or death on the waiting list. The postoperative outcome, however, was excellent with a 5-year survival rate of 85%.