Observational Study
Copyright ©The Author(s) 2022. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Oct 28, 2022; 28(40): 5881-5892
Published online Oct 28, 2022. doi: 10.3748/wjg.v28.i40.5881
Liver transplantation is beneficial regardless of cirrhosis stage or acute-on-chronic liver failure grade: A single-center experience
Eduardo Cervantes-Alvarez, Mario Vilatoba, Nathaly Limon-de la Rosa, Osvely Mendez-Guerrero, David Kershenobich, Aldo Torre, Nalu Navarro-Alvarez
Eduardo Cervantes-Alvarez, PECEM, Facultad de Medicina, Universidad Nacional Autónoma de México, Mexico City 14080, Mexico
Eduardo Cervantes-Alvarez, Nathaly Limon-de la Rosa, Osvely Mendez-Guerrero, David Kershenobich, Aldo Torre, Nalu Navarro-Alvarez, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
Mario Vilatoba, Department of Trasplant, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City 14080, Mexico
Nalu Navarro-Alvarez, Department of Molecular Biology, Universidad Panamericana School of Medicine, Mexico City 03920, Mexico
Nalu Navarro-Alvarez, Department of Surgery, University of Colorado Anschutz Medical Campus, Denver, CO 80045, United States
Author contributions: Cervantes-Alvarez E and Navarro-Alvarez N envisioned the study and wrote the manuscript; Cervantes-Alvarez E, Limon-de la Rosa N and Mendez-Guerrero O supported the data collection and made the formal analysis; Navarro-Alvarez N, Kershenobich D, Vilatoba M, Torre A, Limon-de la Rosa N, Mendez-Guerrero O and Cervantes-Alvarez E reviewed and edited the manuscript; all authors read and approved the final manuscript.
Institutional review board statement: This study was reviewed and approved by the Research Ethics Committee of Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán (GAS-2368-17-20).
Informed consent statement: Requirement of informed consent was waived due to the observational nature of this study.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
Data sharing statement: The data that support the findings of this study are available from the corresponding author upon reasonable request.
STROBE statement: The authors have read the STROBE Statement—checklist of items, and the manuscript was prepared and revised according to the STROBE Statement—checklist of items.
Open-Access: This article is an open-access article that was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution NonCommercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: https://creativecommons.org/Licenses/by-nc/4.0/
Corresponding author: Nalu Navarro-Alvarez, MD, PhD, Assistant Professor, Department of Gastroenterology, Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Vasco de Quiroga #15, Mexico City 14080, Mexico. nalu.navarroa@incmnsz.mx
Received: April 25, 2022
Peer-review started: April 25, 2022
First decision: May 30, 2022
Revised: June 21, 2022
Accepted: September 21, 2022
Article in press: September 21, 2022
Published online: October 28, 2022

Liver transplantation for the most critically ill remains controversial; however, it is currently the only curative treatment option.


To assess immediate posttransplant outcomes and compare the short (1 year) and long-term (6 years) posttransplant survival among cirrhotic patients stratified by disease severity.


We included cirrhotic patients undergoing liver transplantation between 2015 and 2019 and categorized them into compensated cirrhosis (CC), decompensated cirrhosis (DC), and acute-on-chronic liver failure (ACLF). ACLF was further divided into severity grades. Our primary outcomes of interest were total days of intensive care unit (ICU) and hospital stay, development of complications and posttransplant survival at 1 and 6 years.


235 patients underwent liver transplantation (CC = 11, DC = 129 and ACLF = 95). Patients with ACLF had a significantly longer hospital stay [8.0 (6.0-13.0) vs CC, 6.0 (3.0-7.0), and DC 7.0 (4.5-10.0); P = 0.01] and developed more infection-related complications [47 (49.5%), vs CC, 1 (9.1%) and DC, 38 (29.5%); P < 0.01]. Posttransplant survival at 1- and 6-years was similar among groups (P = 0.60 and P = 0.90, respectively). ACLF patients stratified according to ACLF grade [ACLF-1 n = 40 (42.1%), ACLF-2 n = 33 (34.7%) and ACLF-3 n = 22 (23.2%)], had similar ICU and hospital stay length (P = 0.68, P = 0.54), as well as comparable frequencies of overall and infectious post-transplant complications (P = 0.58, P = 0.80). There was no survival difference between ACLF grades at 1 year and 6 years (P = 0.40 and P = 0.15).


Patients may benefit from liver transplantation regardless of the cirrhosis stage. ACLF patients have a longer hospital stay and frequency of infectious complications; however, excellent, and comparable 1 and 6-year survival rates support their enlisting and transplantation including those with ACLF-3.

Keywords: Liver transplantation, Acute-on-chronic liver failure, Prognosis, Survival analysis, Critical care

Core Tip: Cirrhotic patients classified into compensated or decompensated cirrhosis and acute-on-chronic liver failure (ACLF) underwent liver transplantation. Patients with ACLF have a longer hospital stay and a higher frequency of infectious complications, but despite that, have similar posttransplant survival at one year and up to 6 years of follow-up.