Transplantation sharply improves survival in severe acute-on-chronic liver failure

Design

Prospective multicentre cohort (63 transplant centres), transplanted vs declined

Population

612 transplanted and 144 declined adults with decompensated cirrhosis and ACLF

Primary outcome

One-year survival after transplantation vs decline

Effect

Declined: 73% (ACLF-2) and 88% (ACLF-3) died; transplanted case-fatality 10.5% and 21%

Whether to transplant patients with the sickest decompensated cirrhosis — those with two (ACLF-2) or three or more (ACLF-3) organ failures — has been uncertain. This prospective study across 63 centres followed both transplanted patients and those declined, for a year.

The contrast was stark. Among those declined, 73% with ACLF-2 and 88% with ACLF-3 died within a year. Among the 612 transplanted, one-year case-fatality was 10.5% with ACLF-2 and 21% with ACLF-3 — but 42% among those with five or six organ failures. The authors caution against routine transplantation at that extreme.

The signal is that severe ACLF should not by itself rule out transplantation, because the survival gap between transplanted and declined patients is large. But this is not a randomised comparison — patients were declined for reasons that themselves predict death — so it cannot be read as proof of transplant benefit in any individual. Notably, post-transplant mortality was higher in Asian centres, a finding Indian programmes should weigh.

• Declined severe ACLF had very high one-year mortality (73% ACLF-2, 88% ACLF-3).
• Transplanted patients fared far better (case-fatality 10.5% ACLF-2, 21% ACLF-3).
• Those with five or six organ failures still had 42% mortality — a limit to routine transplantation.
• Post-transplant mortality was higher in Asian than European or North American centres.

Why it matters

It argues against writing off the sickest cirrhotics for transplant, while marking where the ceiling of benefit lies.

Don't overread it

Transplanted and declined patients were not randomised and differ in ways that predict survival, so the comparison overstates the causal benefit of transplantation.

The statistics, in plain English

The survival difference is huge, but because sicker or otherwise unsuitable patients were the ones declined, part of the gap reflects who was chosen, not what transplantation did.

Read the rest in the app

You have read your two free briefings this month. The app carries all 27 specialties, every morning, free — and this finding is waiting in it.

Get Daily Doctor — free

Scan to keep reading on your phone. No account needed to start.