Liver transplantation is beneficial regardless of cirrhosis stage or acute-on-chronic liver failure grade: A single-center experience

doi:10.3748/wjg.v28.i40.5881

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World Journal of Gastroenterology

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Observational Study

World J Gastroenterol. Oct 28, 2022; 28(40): 5881-5892
Published online Oct 28, 2022. doi: 10.3748/wjg.v28.i40.5881

Table 1 Patient characteristics (n = 235)

	CC, n = 11 (4.5%)	DC, n= 129 (52.9%)	ACLF, n = 95 (38.9%)	P value
Male gender, n (%)	6 (54.5)	64 (49.6)	47 (49.5)	0.95
Age, yr	57.0 (53.0-59.0)^a	52.0 (43.0-61.0)^c	50.0 (37.0-59.0)^a^,^c	0.02
Liver cirrhosis etiology, n (%)
Autoimmune	1 (9.1)^a	36 (27.9)^c	42 (44.2)^a^,^c	< 0.01
HCV	8 (72.7)^a^,^b	42 (32.6)^b^,^c	13 (13.7)^a^,^c	< 0.0001
Alcoholic liver disease	1 (9.1)	11 (8.5)	9 (9.5)	0.93
NASH	0 (0.0)	7 (5.4)	6 (6.3)	0.88
Cryptogenic	1 (9.1)	22 (17.1)	18 (18.9)	0.76
Other¹	0 (0.0)	11 (8.5)	7 (7.4)	0.84
Comorbidities, n (%)
Type 2 diabetes mellitus	3 (27.3)	22 (17.1)	13 (13.7)	0.44
Primary hypertension	2 (18.2)	20 (15.5)	6 (6.3)	0.06
Pre-transplant clinical data
MELD-Na	11 ± 3^a^,^b	19 ± 4^b^,^c	25 ± 6^a^,^c	< 0.0001
Total bilirubin (mg/dL)	1.18 (1.03-1.45)^a^,^b	3.39 (2.3-5.46)^b^,^c	7.70 (4.14-16.63)^a^,^c	< 0.0001
INR	1.1 (1.1-1.2)^a^,^b	1.5 (1.3-1.7)^b	1.5 (1.3-2.0)^a	< 0.0001
Serum creatinine (mg/dL)	0.67 (0.57-0.71)^a	0.73 (0.61-0.88)^c	0.97 (0.75-1.35)^a^,^c	< 0.0001
Leukocyte count (× 10⁹/L)	2.9 (2.4-3)^a	4 (3.1-5)^c	5.4 (3.8-6.8)^a^,^c	< 0.0001
Disease manifestations², n (%)
Clinical ascites	0 (0.0)^a^,^b	88 (68.2)^b^,^c	88 (92.6)^a^,^c	< 0.0001
Encephalopathy	0 (0.0)^a^,^b	69 (53.5)^b^,^c	80 (84.2)^a^,^c	< 0.0001
Grade 3-4 encephalopathy (West- Haven)	0 (0.0)^a^,^b	7 (5.4)^b^,^c	37 (38.9)^a^,^c	< 0.0001

¹Includes secondary biliary cirrhosis, drug-induced liver injury, and congenital liver diseases.

²Disease manifestations during the whole clinical course until liver transplantation.

Comparisons between groups are shown with superscript letters.

^aSignificant difference between CC and ACLF.

^bSignificant difference between CC and DC.

^cSignificant difference between DC and ACLF.

ACLF: Acute-on-chronic liver failure; CC: Compensated cirrhosis; DC: Decompensated cirrhosis; HCV: Hepatitis C virus; INR: International normalized ratio; MELD Na: Model for End-Stage Liver Disease-Sodium; NASH: Non-alcoholic steatohepatitis.

Table 2 Acute-on-chronic liver failure patients characteristics (n = 95)

	ACLF-1,n = 40 (42.1%)	ACLF-2, n = 33 (34.7%)	ACLF-3, n = 22 (23.2%)	P value
Male gender, n (%)	21 (52.5)	17 (51.5)	11 (50.0)	0.98
Age, yr	55.0 (39.8-60.0)	44.0 (36.5-53.0)	49.0 (37.5-59.3)	0.14
Time to LT since ACLF event	54.0 (21.3-122.8)^a^,^b	31.0 (7.0-59.5)^b	22.0 (9.5-46.8)^a	0.03
Liver cirrhosis etiology, n (%)
Autoimmune	14 (35.0)	17 (51.5)	11 (50.0)	0.30
HCV	9 (22.5)	2 (6.1)	2 (9.1)	0.14
Alcoholic liver disease	2 (5.0)	4 (12.1)	3 (13.6)	0.44
NASH	3 (7.5)	2 (6.1)	1 (4.5)	0.99
Cryptogenic	10 (25.0)	5 (15.2)	3 (13.6)	0.50
Other¹	2 (5.0)	3 (9.1)	2 (9.1)	0.69
ACLF precipitant, n (%)
Bacterial infection	14 (35.0)	16 (48.5)	11 (50.0)	0.39
Gastrointestinal hemorrhage	1 (2.5)	3 (9.1)	1 (4.5)	0.44
Active alcoholism	0 (0.0)	0 (0.0)	0 (0.0)	0.99
Other	10 (25.0)^a	2 (6.1)	0 (0.0)^a	0.01
Unknown	15 (37.5)	12 (36.4)	10 (45.5)	0.77
Organ failures, n (%)
Liver	14 (35.0)^a^,^b	22 (66.7)^b	16 (72.7)^a	< 0.01
Kidney	18 (45.0)	11 (33.3)	14 (63.6)	0.09
Brain	5 (12.5)^a	10 (30.3)	11 (50.0)^a	< 0.01
Coagulation	3 (7.5)^a^,^b	12 (36.4)^b	11 (50.0)^a	< 0.001
Circulation	0 (0.0)^a^,^b	8 (24.2)^b^,^c	14 (63.6)^a^,^c	< 0.0001
Lung	1 (2.5)^a	3 (9.1)	7 (31.8)^a	< 0.01
ACLF event clinical data
MELD-Na	27 ± 4^a^,^b	29 ± 5^b^,^c	35 ± 4^a^,^c	< 0.0001
CLIF-C OF	9 ± 1^a^,^b	10 ± 1^b^,^c	12 ± 2^a^,^c	< 0.0001
CLIF-C ACLF	39 ± 8^a	43 ± 6^c	52 ± 6^a^,^c	< 0.0001
Total bilirubin (mg/dL)	6.31 (2.99-12.91)^a^,^b	13.07 (6.39-22.31)^b	23.08 (10.56-27.76)^a	< 0.001
INR	1.5 (1.2-1.9)^a^,^b	1.9 (1.4-2.5)^b	2.2 (1.7-2.8)^a	< 0.001
Serum creatinine (mg/dL)	1.86 (1.18-2.27)^b	0.93 (0.71-1.99)^b^,^c	2.25 (1.42-2.87)^c	< 0.01
Leukocyte count (× 10⁹/L)	6.55 (4.73-9.43)^a	6.60 (4.55-8.25)^c	8.75 (6.88-13.05)^a^,^c	< 0.01
Pre-transplant clinical data
MELD-Na	23 ± 4^a	25 ± 5^c	29 ± 8^a^,^c	< 0.0001
CLIF-C OF	8 ± 2^a	9 ± 2	10 ± 2^a	0.01
CLIF-C ACLF	37 ± 9	37 ± 8	41 ± 12	0.18
Total bilirubin (mg/dL)	4.58 (2.94-8.60)^a	9.75 (5.40-16.62)	19.59 (5.48-34.11)^a	< 0.01
INR	1.4 (1.3-1.7)	1.6 (1.3-2.2)	1.9 (1.4-2.6)	0.05
Serum creatinine (mg/dL)	0.96 (0.75-1.29)^a	0.88 (0.72-1.17)^c	1.23 (0.94-1.95)^a^,^c	< 0.01
Leukocyte count (× 10⁹/L)	4.40 (3.23-6.70)	4.80 (2.90-6.30)	4.75 (2.48-10.45)	0.92

¹Includes secondary biliary cirrhosis, drug-induced liver injury, and congenital liver diseases.

Comparisons between groups are shown with superscript letters.

^aSignificant difference between CC and ACLF.

^bSignificant difference between CC and DC.

^cSignificant difference between DC and ACLF.

ACLF: Acute-on-chronic liver failure; CLIF-C OF: Chronic Liver Failure Consortium: Organ Failure score; CLIF-C ACLF: Chronic Liver Failure Consortium: acute-on-chronic liver failure score; HCV: Hepatitis C virus; INR: International normalized ratio; MELD Na: Model for End-Stage Liver Disease-Sodium; NASH: Non-alcoholic steatohepatitis.

Table 3 Posttransplant outcomes (n = 235)

	CC, n = 11 (4.5%)	DC, n = 129 (52.9%)	ACLF, n = 95 (38.9%)	P value
ICU stay (d)	2.0 (1.0-4.0)	2.0 (1.5-4.0)	3.0 (2.0-5.0)	0.05
Hospital stay (d)	6.0 (3.0-7.0)^a	7.0 (4.5-10.0)	8.0 (6.0-13.0)^a	0.01
Any type of complication, n (%)	7 (63.6)	105 (81.4)	85 (89.5)	0.05
Infectious complications, n (%)	1 (9.1)^a	38 (29.5)^b	47 (49.5)^a^,^b	< 0.01
Complications (Clavien-Dindo), n (%)
I	4 (36.4)	17 (13.2)	19 (20.0)	0.08
II	2 (18.2)	51 (39.5)	32 (33.7)	0.31
III	1 (9.1)	14 (10.9)	17 (17.9)	0.27
IV	0 (0.0)	9 (7.0)	12 (12.6)	0.23
V	0 (0.0)	14 (10.9)	5 (5.3)	0.24

Comparisons between groups are shown with superscript letters.

^aSignificant difference between CC and ACLF.

^bSignificant difference between CC and DC.

^cSignificant difference between DC and ACLF.

ACLF: Acute-on-chronic liver failure; CC: Compensated cirrhosis; DC: Decompensated cirrhosis; ICU: Intensive care unit.

Table 4 Acute-on-chronic liver failure posttransplant outcomes (n = 95)

	ACLF-1, n = 40 (42.1%)	ACLF-2, n = 33 (34.7%)	ACLF-3, n = 22 (23.2%)	P value
ICU stay (d)	3.0 (2.0-4.0)	3.0 (2.0-6.0)	3.0 (2.0-6.0)	0.68
Hospital stay (d)	8.0 (5.0-11.8)	8.0 (6.0-15.5)	6.0 (5.8-14.3)	0.54
Any type of complication, n (%)	35 (87.5)	31 (93.9)	19 (86.4)	0.58
Infectious complications, n (%)	20 (50.0)	15 (45.5)	12 (54.5)	0.80
Complications (Clavien-Dindo), n (%)
I	7 (17.5)	6 (18.2)	6 (27.3)	0.62
II	17 (42.5)	11 (33.3)	4 (18.2)	0.15
III	5 (12.5)	7 (21.2)	5 (22.7)	0.50
IV	4 (10.0)	6 (18.2)	2 (9.1)	0.49
V	2 (5.0)	1 (3.0)	2 (9.1)	0.61

ACLF: Acute-on-chronic liver failure; ICU: Intensive care unit.

Table 5 Posttransplant survival overall and by acute-on-chronic liver failure grade, n (%)

	CC, n = 11 (4.5%)	DC, n = 129 (52.9%)	ACLF, n = 95 (38.9%)	P value	ACLF-1, n = 40 (42.1%)	ACLF-2, n = 33 (34.7%)	ACLF-3, n = 22 (23.2%)	P value
DRI	1.41 (1.36-2.26)	1.38 (1.21-1.53)	1.32 (1.19-1.54)	0.13	1.43 (1.24-1.62)	1.27 (1.20-1.43)	1.38 (1.20-1.69)	0.08
30-d mortality	0 (0.0)	10 (7.8)	3 (3.2)	0.38	1 (2.5)	0 (0.0)	2 (9.1)	0.17
3-mo mortality	0 (0.0)	15 (11.6)	6 (6.3)	0.30	3 (7.5)	1 (3.0)	2 (9.1)	0.65
1-yr survival	11 (100)	114 (88.4)	87 (91.6)	0.60	35 (87.5)	32 (97.0)	20 (90.9)	0.40
Overall survival¹	10 (90.9)	112 (86.8)	80 (84.2)	0.90	32 (80.0)	31 (93.9)	17 (77.3)	0.15

¹Survival was analyzed until 6 years of follow-up, when the study was ended.

ACLF: Acute-on-chronic liver failure; CC: Compensated cirrhosis; DC: Decompensated cirrhosis.

Citation: Cervantes-Alvarez E, Vilatoba M, Limon-de la Rosa N, Mendez-Guerrero O, Kershenobich D, Torre A, Navarro-Alvarez N. Liver transplantation is beneficial regardless of cirrhosis stage or acute-on-chronic liver failure grade: A single-center experience. World J Gastroenterol 2022; 28(40): 5881-5892
URL: https://www.wjgnet.com/1007-9327/full/v28/i40/5881.htm
DOI: https://dx.doi.org/10.3748/wjg.v28.i40.5881