Meta-Analysis
Copyright ©The Author(s) 2025. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Gastroenterol. Mar 28, 2025; 31(12): 102007
Published online Mar 28, 2025. doi: 10.3748/wjg.v31.i12.102007
Liver transplantation improves prognosis across all grades of acute-on-chronic liver failure patients: A systematic review and meta-analysis
Zhi-Xin Li, Jun-Hao Zeng, Hong-Lin Zhong, Bo Peng
Zhi-Xin Li, Department of General Surgery, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
Zhi-Xin Li, Clinical Research Center, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
Jun-Hao Zeng, Xiangya School of Medicine, Central South University, Changsha 410013, Hunan Province, China
Hong-Lin Zhong, Department of Urology, Xiangya Hospital, Central South University, Changsha 410008, Hunan Province, China
Bo Peng, The Transplantation Center, The Third Xiangya Hospital, Central South University, Changsha 410013, Hunan Province, China
Bo Peng, Key Laboratory of Translational Research on Transplantation Medicine, National Health Commission, Changsha 410013, Hunan Province, China
Author contributions: Li ZX and Zeng JH contributed to the literature search; Li ZX participated in the meta-analysis, table and figure generation, and manuscript writing; Zeng JH and Zhong HL participated in the quality assessment; Zhong HL participated in the manuscript editing; Li ZX and Peng B contributed to the data collection; Peng B was responsible for review conception, protocol design, supervision, and review of manuscript.
Supported by National Natural Science Foundation of China, No. 82300857.
Conflict-of-interest statement: All the authors report no relevant conflicts of interest for this article.
PRISMA 2009 Checklist statement: The authors have read the PRISMA 2009 Checklist, and the manuscript was prepared and revised according to the PRISMA 2009 Checklist.
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: Bo Peng, MD, The Transplantation Center, The Third Xiangya Hospital, Central South University, No. 138 Tongzipo Road, Yuelu District, Changsha 410013, Hunan Province, China. pengbo_2000@163.com
Received: October 5, 2024
Revised: January 23, 2025
Accepted: February 26, 2025
Published online: March 28, 2025
Processing time: 171 Days and 18.1 Hours
Abstract
BACKGROUND

Liver transplantation (LT) is recognized as an effective approach that offers survival benefits for patients with acute-on-chronic liver failure (ACLF). However, controversies remain regarding the LT selection criteria, and meta-analyses reporting overall survival outcomes across different ACLF severity grades are lacking.

AIM

To depict a comprehensive postoperative picture of patients with ACLF of varying severity and contribute to updating LT selection.

METHODS

Systematic searches in Web of Science, EMBASE, PubMed, and Cochrane databases were performed, from inception to December 26, 2023, for studies exploring post-transplant outcomes among ACLF patients, stratified by severity grades as identified by the European Association for the Study of the Liver-Chronic Liver Failure criteria. The primary outcome of interest was the survival rate within one year, with post-transplant complications as secondary outcomes. Additionally, the subgroup analysis examined region-specific one-year survival rates.

RESULTS

A total of 17 studies involving 28025 participants were included. Patients with ACLF-1 and ACLF-2 have favorable survival within one year, with survival rates reaching 87% [95% confidence interval (CI): 84%-91%] and 86% (95%CI: 81%-91%), respectively. Despite the relatively lower survival (73%, 95%CI: 66%-80%) and higher incidence of infection (48%, 95%CI: 29%-67%) observed in ACLF-3 patients, their survival exceeds that of those who do not undergo LT. Moreover, post-transplant survival was highest in North America across all ACLF grades.

CONCLUSION

LT can provide survival advantages for ACLF patients. To optimize the utilization of scarce donor organs and improve prognosis, comprehensive preoperative health evaluations are essential, especially for ACLF-3 patients.

Keywords: Acute-on-chronic liver failure; Liver transplantation; Postoperative prognosis; Survival rate; Infection; Meta-analysis

Core Tip: Given the challenges associated with liver transplantation (LT) in the treatment of acute-on-chronic liver failure (ACLF), it is crucial to evaluate patient prognosis across different ACLF grades following LT. This meta-analysis revealed that ACLF-1 and ACLF-2 patients achieve favorable survival outcomes following LT. Although ACLF-3 patients exhibit relatively lower survival rates and higher infection rates, LT remains a promising option to improve their prognosis. To optimize the use of limited donor organs, further refinement of organ allocation and scoring systems is imperative. A comprehensive assessment of pre-transplant health status, concurrent organ failure, and donor characteristics should be performed before LT.