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World J Gastroenterol. Dec 28, 2022; 28(48): 6922-6934
Published online Dec 28, 2022. doi: 10.3748/wjg.v28.i48.6922
Current and future perspectives on acute-on-chronic liver failure: Challenges of transplantation, machine perfusion, and beyond
Bianca Della Guardia, Amanda P C S Boteon, Celso E L Matielo, Guilherme Felga, Yuri L Boteon
Bianca Della Guardia, Amanda P C S Boteon, Celso E L Matielo, Guilherme Felga, Yuri L Boteon, Liver Unit, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
Yuri L Boteon, Instituto Israelita de Ensino e Pesquisa Albert Einstein, Faculdade Israelita de Ciências da Saúde Albert Einstein, São Paulo 05652-900, Brazil
Author contributions: Boteon YL, Della Guardia B, and Boteon APCS designed this study; Boteon YL, Della Guardia B, Boteon APCS, Matielo CE, and Felga G performed the literature review and analysis; Boteon YL, Della Guardia B, and Boteon APCS drafted the manuscript; Boteon YL, Della Guardia B, Boteon APCS, Matielo CE, and Felga G reviewed the manuscript critically; All authors contributed to editing and approving the final manuscript version.
Conflict-of-interest statement: The authors have no conflicts of interest to declare.
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: Yuri L Boteon, MD, PhD, Professor, Surgeon, Liver Unit, Hospital Israelita Albert Einstein, Transplant Centre, Hospital Israelita Albert Einstein, 2nd floor, building A1, Office 200B, 627/701 Albert Einstein Avenue, São Paulo 05652-900, Brazil. yuri.boteon@einstein.br
Received: September 25, 2022
Peer-review started: September 25, 2022
First decision: October 30, 2022
Revised: November 1, 2022
Accepted: November 25, 2022
Article in press: December 18, 2022
Published online: December 28, 2022
Abstract

Acute-on-chronic liver failure (ACLF) is a syndrome that occurs in patients with chronic liver disease and is characterized by acute decompensation, organ failure and high short-term mortality. Partially due to the lack of universal diagnostic criteria, the actual ACLF prevalence remains unclear; nevertheless, it is expected to be a highly prevalent condition worldwide. Earlier transplantation is an effective protective measure for selected ACLF patients. Besides liver trans-plantation, diagnosing and treating precipitant events and providing supportive treatment for organ failures are currently the cornerstone of ACLF therapy. Although new clinical specific therapies have been researched, more studies are necessary to assess safety and efficacy. Therefore, future ACLF management strategies must consider measures to improve access to liver transplantation because the time window for this life-saving therapy is frequently narrow. Thus, an urgent and global discussion about allocation and prioritization for transplantation in critically ill ACLF patients is needed because there is evidence suggesting that the current model may not portray their waitlist mortality. In addition, while donor organ quality is meant to be a prognostic factor in the ACLF setting, recent evidence suggests that machine perfusion of the liver may be a safe tool to improve the donor organ pool and expedite liver transplantation in this scenario.

Keywords: Acute-on-chronic liver failure, Liver cirrhosis, Liver transplantation, Machine perfusion, Hypothermic oxygenated machine perfusion

Core Tip: Acute-on-chronic liver failure (ACLF) is characterized by high short-term mortality. Although new clinical specific therapies have been researched, more studies are necessary to assess safety and efficacy. Conversely, earlier transplantation is effective for selected patients. Therefore, future ACLF management strategies must consider measures to improve access to liver transplantation. Discussions about donor organ allocation and recipient prioritization are necessary because there is evidence suggesting the current model may not portray the waitlist mortality of these patients. In this scenario, machine perfusion of the liver may prove to be a safe tool to improve the donor organ pool.