Patient Selection for Living Donor Liver Transplantation in Acute-on-chronic Liver Failure

Abu Bakar H Bhatti; Syeda F Qasim; Zamrood Zamrood; Shahzad Riyaz; Nusrat Y Khan; Haseeb H Zia; Muslim Atiq

doi:10.1016/j.jceh.2024.101403

Patient Selection for Living Donor Liver Transplantation in Acute-on-chronic Liver Failure

J Clin Exp Hepatol. 2024 Sep-Oct;14(5):101403. doi: 10.1016/j.jceh.2024.101403. Epub 2024 Mar 26.

Authors

Abu Bakar H Bhatti^{1

2}, Syeda F Qasim¹, Zamrood Zamrood¹, Shahzad Riyaz^{2

3}, Nusrat Y Khan¹, Haseeb H Zia^{1

2}, Muslim Atiq^{2

3}

Affiliations

¹ Department of Hepato-Pancreatico-Biliary Surgery and Liver Transplantation, Shifa International Hospital, Islamabad, Pakistan.
² Shifa Tameer-e-Millat University, Pakistan.
³ Department of Gastroenterology and Hepatology, Shifa International Hospital, Islamabad, Pakistan.

PMID: 38660560
PMCID: PMC11036089 (available on 2025-09-01)
DOI: 10.1016/j.jceh.2024.101403

Abstract

Background and objectives: Acute-on-chronic liver failure (ACLF) is associated with high short-term mortality without liver transplantation (LT). The selection criteria for LT in these patients are not well defined. The objective of this study was to determine factors associated with post-transplant survival in ACLF.

Methods: This was a single-center retrospective study of patients who underwent living donor liver transplantation (LDLT) for ACLF between 2012 and 2022. Out of 1093 transplants, 110 patients had underlying ACLF, based on the European Association for the Study of the Liver-Chronic Liver Failure Consortium (EASL-CLIF) criteria. We looked at factors associated with 1-year posttransplant survival.

Results: The median model for end-stage liver disease (MELD) score was 33.5 (31-38), and the 1-year posttransplant survival was 72%. Six risk factors were associated with posttransplant survival, namely, body mass index > 30 kg/m² [HR, 4.4; 95% CI, 1.8-10.7], platelet count < 66,000/μl [HR, 2.91; CI,1.2-6.6], poor response to medical treatment [HR, 2.6; CI, 1.1-5.7], drug-resistant bacterial or fungal cultures [HR, 4.2; CI, 1.4-12.4], serum creatinine > 2.5 mg/dl [HR, 3.4; CI, 1.5-7.7], and graft-to-recipient weight ratio < 0.7 [HR, 4.8; CI, 1.4-16.3]. The 1-year post-transplant survival was 84% in patients with 0-2 risk factors (n = 89) and was 6% with 3 risk factors (n = 15) (P < 0.001). For 1-year posttransplant survival, the area under curve (AUC) for the current model was 0.8 (0.69-0.9). The AUC for CLIF-ACLF, Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA), and EASL-CLIF ACLF grades was < 0.5.

Conclusion: In LT for ACLF, acceptable survival can be achieved when less than three high-risk factors are present.

Keywords: European Association for the Study of the Liver-Chronic Liver Failure Consortium; graft to recipient weight ratio; living donor liver transplantation; mortality; multidrug resistant infection.