Low rates of positive evaluation and early liver transplantation (LT) for acute-on-chronic liver failure (ACLF) in a European tertiary referral center

Background: Identification of LT candidates and organ allocation in the management of ACLF remain controversial. Aim: To evaluate the LT evaluation process and outcomes in ACLF patients in a tertiary transplant center.

Methods: LT evaluations, listings and outcomes of all adult ACLF patients at the University Medical Center Hamburg-Eppendorf were prospectively assessed between 12/21 and 06/24.

Results: 132 ACLF patients were enrolled (41 ACLF I°, 31 ACLF II°, 60 ACLF III°). Of 17 patients previously listed for LT, 13 (76%) underwent LT. In the 115 non-listed patients, LT evaluation revealed contraindications in 69 cases, mostly alcoholism and/or transplant-psychological factors (50/69). In 46 patients eligible for listing, mortality was 50%: 23 patients were never listed, mostly due to infections, and 19/23 died. 23 patients were newly listed for LT with a median time from ACLF diagnosis to listing of 14 days, and 16 patients (69.6%) underwent LT. Overall ACLF-LT 6-month survival was 89.1%, contrasting 30.9% in the ACLF non-LT group. Of 68 non-LT patients surviving to hospital discharge, 40 (58.8%) developed recurrent ACLF, and 24 (35.3%) of these patients died within 6 months of ACLF diagnosis.

Conclusion: In this single-center prospective study, only a minority (22%) of ACLF patients underwent LT. Despite timely identification of ACLF-LT candidates, mortality among previously non-listed patients was 50%, contrasting 17.6% in patients listed prior to ACLF (p<0.05). Recurrent ACLF constitutes a significant risk in ACLF non-LT patients, and identification of patients at ACLF risk and early listing of LT candidates may improve prognosis.

Publication History

Article published online:
20 January 2025