PATIENTS with severe acute-on-chronic liver failure (ACLF) faced higher mortality rates than those without ACLF while waiting to receive a liver transplant, according to a recent study carried out in the UK. This was found to be the case despite the two groups having similar survival rates after transplant.
ACLF is a condition characterized by multiorgan failure and very high risk of death, occurring in patients with cirrhosis who acutely decompensate. According to previous research, the risk of death at 28 days among patients with ACLF 2 or 3 is between 30-90%. This study, presented at the European Association for the Study of the Liver (EASL) annual congress in June, involved analysing results from 823 patients from 66 liver transplant centres across 21 countries in Asia, Europe, Latin America, and North America.
When researchers looked at mortality by ACLF severity according to MELD-sodium (Na) scores, 50% of those with ACLF 2 and 3 with a MELD-Na score of less than 25 died while waiting for a transplant. “This suggests that these patients are disadvantaged on the current waiting list programs,” commented lead author, Rajiv Jalan, University College London, UK. In a group with severe ACLF who were referred for waitlist evaluation but were not listed (Group 3), 85% died. Notably, the main aetiology of liver disease in Group 3 was alcohol-associated cirrhosis, compared with 56% and 48% of Groups 1 and 2 (p<0.001). Jalan and colleagues also looked at 3-month mortality rates after transplant by ACLF grades at time of transplantation. In Group 1, 9% of patients who received a transplant at 3 months and 7% in Group 2 died. The risk of death post-transplant even in ACLF grade 2 or 3 was not significantly different (p=0.051) from those who have decompensated cirrhosis, Jalan reported.
“What we need to do is to generate a score, which is numbers-based rather than based upon how physicians see the patient,” commented Jalen when addressing how to come up with an objective, verifiable indicator for treatment. The study results provided a strong argument for increasing access to liver transplantation in a possible change in the organ allocation system for this population of patients with very severe ACLF. Jalen concluded by urging practitioners to reconsider transplant allocation.
Victoria Antoniou, EMJ
Reference
Jalan R. Current graft allocation policies underestimate the mortality of patients with severe acute-on-chronic liver failure on the transplant waiting list: Interim results of the CHANCE study. Presentation LBO-004. EASL Annual Meeting, 5-8 June, 2024.
