Patient Selection for Living Donor Liver Transplantation in Acute-on-chronic Liver Failure

Abstract

Background and objectivesAcute-on-chronic liver failure (ACLF) is associated with high short-term mortality without liver transplantation (LT). Selection criteria for LT in these patients are not well defined. The objective of this study was to determine factors associated with post-transplant survival in ACLF. MethodsThis was a single center retrospective study of patients who underwent living donor liver transplantation (LDLT) for ACLF between 2012 and 2022. Out of 1093 transplants, 110 patients had underlying ACLF, based on the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria. We looked at factors associated with 1-year post-transplant survival. ResultsThe median (IQR) MELD score was 33.5(31-38) and the 1-year post-transplant survival was 72%. Six risk factors were associated with post-transplant survival, namely, body mass index >30 Kg/m2 [HR, 4.4; 95% CI,1.8-10.7], platelet count <66000/μl [HR, 2.91; CI,1.2-6.6], poor response to medical treatment [HR, 2.6; CI, 1.1-5.7], drug-resistant bacterial or fungal cultures [HR, 4.2; CI, 1.4-12.4], serum creatinine >2.5 mg/dl [HR, 3.4; CI, 1.5-7.7 ], and graft-to-recipient weight ratio < 0.7 [HR, 4.8; CI, 1.4-16.3]. The 1-year post-transplant survival was 84% in patients with 0-2 risk factors (n=89) and was 6% with 3 risk factors (n=15) (P<0.001). For 1-year post-transplant survival, the area under curve (AUC) for the current model was 0.8 (0.69-0.9). The AUC for CLIF-ACLF, CLIF-SOFA, and EASL-CLIF ACLF grade was < 0.5. ConclusionIn LT for ACLF, acceptable survival can be achieved when less than three high risk factors are present.