Transplant in ACLF: good outcomes up to grade 2, high risk with five or six organ failures

Design

Prospective multicentre cohort, 63 transplant centres

Population

612 transplanted patients with decompensated cirrhosis ± ACLF; 144 declined with ACLF-2/3

Primary outcome

One-year mortality

Effect

Post-transplant 9% no ACLF, 10.5% ACLF-2, 21% ACLF-3; declined ACLF-3 88%

A prospective study at 63 transplant centres worldwide followed 612 patients with decompensated cirrhosis, with or without acute-on-chronic liver failure, through their first year after liver transplantation, along with 144 patients with ACLF-2 or ACLF-3 who were declined.

One-year mortality after transplant was 9% without ACLF, 10% with ACLF-1, 10.5% with ACLF-2 and 21% with ACLF-3, rising to 42% with five or six organ failures. Among those declined, 73% with ACLF-2 and 88% with ACLF-3 died within the year. Transplantation in Asia was associated with higher post-transplant mortality than in Europe or North America.

This was not randomised, and declined patients were likely sicker in ways the grade does not capture. But the contrast is stark enough to support early referral and listing for ACLF-2 and ACLF-3, while recognising that five or six organ failures marks a group where transplant often fails. For Indian centres, which rely heavily on living donors, the higher mortality seen in Asian centres deserves examination rather than assumption.

• Refer patients with ACLF to a transplant centre early, before organ failures accumulate.
• Grade ACLF formally and reassess daily, as grade at transplant predicted outcome.
• Discuss transplant futility openly when five or six organs have failed.
• Treat infection and support organs aggressively to keep patients transplantable.

Why it matters

It gives transplant teams numbers for the hardest listing decisions in hepatology.

Don't overread it

Declined patients were not a randomised control, so the survival gain from transplant may be overstated.

The statistics, in plain English

These are observed death rates, not a randomised comparison. The difference between transplanted and declined patients is large, but declined patients may have had unmeasured reasons for worse prognosis.

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