Transplantation improved survival in ACLF-2 and ACLF-3, but five or six organ failures carried 42% mortality

Design

Prospective international observational study at 63 transplant centres, 1-year follow-up

Population

612 transplanted patients with decompensated cirrhosis and 144 declined patients with ACLF-2 or ACLF-3

Primary outcome

One-year mortality by ACLF grade and transplant status

Effect

Declined: 73% (ACLF-2) and 88% (ACLF-3) died; transplanted ACLF-3 21% (42% with 5 to 6 organ failures); ACLF-2 10.5%

This prospective international study enrolled adults with decompensated cirrhosis, with or without acute-on-chronic liver failure (ACLF grades 1 to 3), who underwent liver transplantation at 63 centres from 2021 to 2023, and followed them for one year. Patients with ACLF-2 or ACLF-3 who were declined for transplantation were followed too.

Of 144 declined patients, 73% with ACLF-2 and 88% with ACLF-3 died within a year. Of 612 transplanted patients, 2% were re-transplanted and 12% died. Case fatality without re-transplantation was 21% with ACLF-3 at transplant, 42% when five or six organs had failed, 10.5% with ACLF-2, 10% with ACLF-1 and 9% without ACLF. ACLF-3 patients had longer intensive care stays but similar ward stay, readmission and long-term dialysis needs. After adjustment, ACLF-3 and transplantation in Asia (compared with Europe or North America) were associated with higher post-transplant mortality.

The groups were not randomised. Declined patients may have been judged too sick or unsuitable, so the comparison favours transplantation to an uncertain degree. The authors caution against routine transplantation at five or six organ failures.

• Refer patients with ACLF-2 or ACLF-3 early for transplant assessment; most who were declined died within a year.
• Post-transplant mortality in ACLF-2 (10.5%) was close to patients without ACLF (9%).
• At five or six organ failures, post-transplant mortality was 42%; discuss goals carefully.
• Region was linked to post-transplant mortality; Asia had higher risk than Europe or North America in this analysis.
• Organ failures change quickly, so repeat the ACLF grade assessment before listing decisions.

Why it matters

It gives numbers to a decision often made on instinct: whether transplantation is futile in very sick patients.

Don't overread it

Observational comparison of transplanted and declined patients; selection and unmeasured differences are likely.

The statistics, in plain English

The 88% vs 21% contrast in ACLF-3 compares different groups: declined patients were often too sick or ineligible, so the gap overstates what transplantation alone achieves. Case fatality of 42% with five or six organ failures means about two in five died.

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