Transplant in severe ACLF: one-year death 21% after transplant versus 88% when declined

Design

International prospective cohort, 63 transplant centres

Population

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

Primary outcome

One-year mortality

Effect

Declined: 73% (ACLF-2), 88% (ACLF-3); transplanted: 10.5% (ACLF-2), 21% (ACLF-3)

This prospective study enrolled adults with decompensated cirrhosis undergoing liver transplant at 63 centres worldwide in 2021–2023, and also followed patients with ACLF grade 2 or 3 who were declined.

Among 144 declined patients, one-year mortality was 73% with ACLF-2 and 88% with ACLF-3. Among 612 transplanted, one-year case fatality 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. ACLF-3 meant longer ICU stays but similar ward stay, readmission and long-term dialysis need. Transplantation in Asia, compared with Europe or North America, was independently associated with higher post-transplant mortality.

Declined and transplanted patients differ in ways that cannot be fully adjusted, so the survival gap overstates the effect of transplant itself. But the absolute numbers support early referral for ACLF-2 and selected ACLF-3, and caution in five- or six-organ failure.

• Refer patients with ACLF-2 or ACLF-3 early for transplant assessment.
• Post-transplant survival with ACLF-2 was similar to no ACLF.
• Five or six organ failures carried 42% post-transplant mortality; weigh this carefully.
• Note the higher post-transplant mortality in Asian centres when counselling.

Why it matters

It challenges the reflex that patients with multiple organ failures are too sick to transplant.

Don't overread it

Declined patients were not a randomised comparison group, so the survival gap partly reflects selection.

The statistics, in plain English

These are one-year case-fatality percentages in each group, not adjusted treatment effects. The multivariable analysis identified ACLF-3 and transplant region as independent predictors.

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