Liver, Pancreas and Biliary Tract| Volume 53, ISSUE 8, P1004-1010, August 2021

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Predictors and outcome of emergent Liver transplantation for patients with acute-on-chronic liver failure

Published:April 27, 2021DOI:


      Background and aims

      Controversy exists over whether emergent liver transplantation (LT) should be performed for patients with acute-on-chronic liver failure (ACLF), especially for patients with multiple organ failure.


      A total of 110 ACLF patients, defined by the European Association for the Study of the Liver (EASL) Chronic Liver Failure-Sequential Organ Failure Assessment (CLIF-SOFA) criteria were analyzed. The primary outcome was overall survival after ACLF diagnosis.


      During follow-up, 76 patients received LT (59 received deceased-donor LT and 17 patients received living-donor LT). The overall survival was better for patients who received LT than patients who did not (82.9% vs. 17.6%, P < 0.001). Among the 76 patients who received LT, the overall survival was not different according to ACLF grade at diagnosis (70.0%, 85.3%, and 84.4% at one-year for ACLF grades 1, 2, and 3, respectively, P=0.45). The baseline model for end-stage liver disease (MELD) score and progression of the ACLF grade during the pre-transplant period were independent factors for survival after LT. The one-year survival rate was 92.3% for patients with baseline MELD scores of ≤ 32 without ACLF grade progression, whereas it was 33.3% for those with baseline MELD scores of > 32 and ACLF grade progression.


      Emergent LT provided a significant survival benefit to ACLF patients, regardless of the baseline ACLF grade. Post-LT outcomes were associated with baseline MELD scores and ACLF progression during the pre-transplant period, which might be used in the emergent LT plan for patients presenting with ACLF.


      Abbreviations: LT (liver transplantation), ACLF (acute-on-chronic liver failure), EASL (European Association for the Study of the Liver), CLIF-SOFA (Chronic Liver Failure-Sequential Organ Failure Assessment), MELD (model for end-stage liver disease), LDLT (living donor liver transplantation), UNOS (United Network for Organ Sharing), DDLT (deceased donor liver transplantation)
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      Linked Article

      • Reply to “Emergent liver transplantation for patients with acute-on-chronic liver failure”
        Digestive and Liver DiseaseVol. 53Issue 10
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          We would like to express our gratitude to Dr Li., for the interest and comments on our study [1]. Dr. Li pointed out the importance of medication (such as antibiotics and antiviral drugs) for the treatment of acute on chronic liver failure (ACLF) patients, and questioned the drug treatment strategy and percentage of antiviral resistance for patients with chronic hepatitis B virus (HBV) infection between groups. As pointed out by Dr Li, reactivation of HBV, either spontaneously or by emergence of drug-resistance, can be an important cause of ACLF, and appropriate antiviral therapy can improve patient survival [2,3].
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      • Emergent liver transplantation for patients with acute-on-chronic liver failure
        Digestive and Liver DiseaseVol. 53Issue 10
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          Recently, a cohort study based on the Korean population explored the predictors and prognostic parameters for patients with acute-on-chronic liver failure (ACLF) after emergent liver transplantation (LT) [1]. In this study, the authors adjusted for confounding factors using multivariable Cox regression analysis and found that ACLF patients benefited significantly from emergency LT compared with those without emergency LT. The conclusion of this study provides essential evidence for the treatment of ACLF patients, and is conducive to further improve the prognosis of ACLF patients.
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