Luca S Belli1, Christophe Duvoux2, Thierry Artzner3, William Bernal4, Sara Conti5, Paolo A Cortesi5, Sophie-Caroline Sacleux6, George-Philippe Pageaux7, Sylvie Radenne8, Jonel Trebicka9, Javier Fernandez10, Giovanni Perricone11, Salvatore Piano12, Silvio Nadalin13, Maria C Morelli14, Silvia Martini15, Wojciech G Polak16, Krzysztof Zieniewicz17, Christian Toso18, Marina Berenguer19, Claudia Iegri20, Federica Invernizzi21, Riccardo Volpes22, Vincent Karam23, René Adam23, François Faitot3, Liane Rabinovich4, Faouzi Saliba6, Lucy Meunier7, Mickael Lesurtel8, Frank E Uschner24, Costantino Fondevila10, Baptiste Michard3, Audrey Coilly6, Magdalena Meszaros7, Domitille Poinsot8, Andreas Schnitzbauer24, Luciano G De Carlis25, Roberto Fumagalli26, Paolo Angeli12, Vincente Arroyo27, Rajiv Jalan28. 1. Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy. Electronic address: luca.belli@ospedaleniguarda.it. 2. Hôpital Henri Mondor, Service d'Hepatologie, Créteil, France. 3. C.H.R.U. De Strasbourg, Hôpital Hautepierre, Strasbourg, France. 4. Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London UK. 5. Value-Based Healthcare Unit, IRCCS Multi Medica, Sesto San Giovanni, Italy; Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy. 6. AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Villejuif, France; Unité INSERM 1193, Université Paris-Saclay, France. 7. Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, University of Montpellier, France. 8. Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, HCL Hopital de la Croix-Rousse, Lyon, France. 9. Translational Hepatology, Department of Internal Medicine, Goethe University, Frankfurt, Germany; European Foundation for the Study of Chronic Liver Failure (EF Clif), 08021 Barcelona, Spain. 10. Liver ICU, Liver Unit, Institute of Digestive and Metabolic Diseases, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Barcelona, Spain. 11. Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy. 12. Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Italy. 13. Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Germany. 14. IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy. 15. Gastro-hepatology Unit, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy. 16. Erasmus MC, Transplant Institute, University Medical Center Rotterdam Department of Surgery, Division of HPB and Transplant Surgery, Rotterdam, Rotterdam, the Netherlands. 17. Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland. 18. Division of Abdominal Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland. 19. Hepatology and Liver Transplantation Unit, Ciberehd, and Facultad de Medicina, La Fe University Hospital, Valencia, Spain. 20. Gastroenterology Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy. 21. Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Division of Gastroenterology and Hepatology, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Milan, Italy. 22. Hepatology and Gastroenterology Unit, ISMETT-IRCCS, Palermo, Italy. 23. European Liver Transplant Registry, Centre Hépatobiliaire Hôpital Universitaire Paul Brousse, Villejuif, France. 24. Translational Hepatology, Department of Internal Medicine, Goethe University, Frankfurt, Germany. 25. General Surgery and Transplantation Unit, ASST GOM Niguarda, Milan, Italy; School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy. 26. Department of Anesthesia, Critical Care, ASST GOM Niguarda, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy. 27. European Foundation for the Study of Chronic Liver Failure (EF Clif), 08021 Barcelona, Spain. 28. European Foundation for the Study of Chronic Liver Failure (EF Clif), 08021 Barcelona, Spain; Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, London, UK.
Abstract
BACKGROUND & AIMS: Liver transplantation (LT) has been proposed as an effective salvage therapy even for the sickest patients with acute-on-chronic liver failure (ACLF). This large collaborative study was designed to assess the current clinical practice and outcomes of patients with ACLF who are wait-listed for LT in Europe. METHODS: This was a retrospective study including 308 consecutive patients with ACLF, listed in 20 centres across 8 European countries, from January 2018 to June 2019. RESULTS: A total of 2,677 patients received a LT: 1,216 (45.4%) for decompensated cirrhosis. Of these, 234 (19.2%) had ACLF at LT: 58 (4.8%) had ACLF-1, 78 (6.4%) had ACLF-2, and 98 (8.1%) had ACLF-3. Wide variations were observed amongst countries: France and Germany had high rates of ACLF-2/3 (27-41%); Italy, Switzerland, Poland and the Netherlands had medium rates (9-15%); and the United Kingdom and Spain had low rates (3-5%) (p <0.0001). The 1-year probability of survival after LT for patients with ACLF was 81% (95% CI 74-87). Pre-LT arterial lactate levels >4 mmol/L (hazard ratio [HR] 3.14; 95% CI 1.37-7.19), recent infection from multidrug resistant organisms (HR 3.67; 95% CI 1.63-8.28), and renal replacement therapy (HR 2.74; 95% CI 1.37-5.51) were independent predictors of post-LT mortality. During the same period, 74 patients with ACLF died on the waiting list. In an intention-to-treat analysis, 1-year survival of patients with ACLF on the LT waiting list was 73% for ACLF-1 or -2 and 50% for ACLF-3. CONCLUSION: The results reveal wide variations in the listing of patients with ACLF in Europe despite favourable post-LT survival. Risk factors for mortality were identified, enabling a more precise prognostic assessment of patients with ACLF. LAY SUMMARY: Acute-on-chronic liver failure (ACLF) is a severe clinical condition for which liver transplantation is an effective therapeutic option. This study has demonstrated that in Europe, referral and access to liver transplantation (LT) for patients with ACLF needs to be harmonised to avoid inequities. Post-LT survival for patients with ACLF was >80% after 1 year and some factors have been identified to help select patients with favourable outcomes.
BACKGROUND & AIMS: Liver transplantation (LT) has been proposed as an effective salvage therapy even for the sickest patients with acute-on-chronic liver failure (ACLF). This large collaborative study was designed to assess the current clinical practice and outcomes of patients with ACLF who are wait-listed for LT in Europe. METHODS: This was a retrospective study including 308 consecutive patients with ACLF, listed in 20 centres across 8 European countries, from January 2018 to June 2019. RESULTS: A total of 2,677 patients received a LT: 1,216 (45.4%) for decompensated cirrhosis. Of these, 234 (19.2%) had ACLF at LT: 58 (4.8%) had ACLF-1, 78 (6.4%) had ACLF-2, and 98 (8.1%) had ACLF-3. Wide variations were observed amongst countries: France and Germany had high rates of ACLF-2/3 (27-41%); Italy, Switzerland, Poland and the Netherlands had medium rates (9-15%); and the United Kingdom and Spain had low rates (3-5%) (p <0.0001). The 1-year probability of survival after LT for patients with ACLF was 81% (95% CI 74-87). Pre-LT arterial lactate levels >4 mmol/L (hazard ratio [HR] 3.14; 95% CI 1.37-7.19), recent infection from multidrug resistant organisms (HR 3.67; 95% CI 1.63-8.28), and renal replacement therapy (HR 2.74; 95% CI 1.37-5.51) were independent predictors of post-LT mortality. During the same period, 74 patients with ACLF died on the waiting list. In an intention-to-treat analysis, 1-year survival of patients with ACLF on the LT waiting list was 73% for ACLF-1 or -2 and 50% for ACLF-3. CONCLUSION: The results reveal wide variations in the listing of patients with ACLF in Europe despite favourable post-LT survival. Risk factors for mortality were identified, enabling a more precise prognostic assessment of patients with ACLF. LAY SUMMARY: Acute-on-chronic liver failure (ACLF) is a severe clinical condition for which liver transplantation is an effective therapeutic option. This study has demonstrated that in Europe, referral and access to liver transplantation (LT) for patients with ACLF needs to be harmonised to avoid inequities. Post-LT survival for patients with ACLF was >80% after 1 year and some factors have been identified to help select patients with favourable outcomes.
Authors: Vinay Sundaram; Sarvanand Patel; Kirti Shetty; Christina C Lindenmeyer; Robert S Rahimi; Gianina Flocco; Atef Al-Attar; Constantine J Karvellas; Suryanarayana Challa; Harapriya Maddur; Janice H Jou; Michael Kriss; Lance L Stein; Alex H Xiao; Ross H Vyhmeister; Ellen W Green; Braidie Campbell; William Cranford; Nadim Mahmud; Brett E Fortune Journal: Liver Transpl Date: 2022-02-09 Impact factor: 6.112
Authors: Brian P Lee; Giuseppe Cullaro; Aidan Vosooghi; Frederick Yao; Sarjukumar Panchal; David S Goldberg; Norah A Terrault; Nadim Mahmud Journal: J Hepatol Date: 2022-01-21 Impact factor: 30.083