Liver transplantation at the extreme: Analysis of outcomes and predictors of futility in patients with acute-on-chronic liver failure grade 3 on maximal life support
Year: 2026
Type: article
Study design: Observational Study
Abstract: BACKGROUND & AIMS: Although patients with grade 3 acute-on-chronic liver failure (ACLF-3), have high mortality, there is a subset requiring maximal life support. We report post liver transplant (LT) outcomes and identify factors associated with futility in extreme ACLF-3 (eACLF-3) recipients, all requiring intubation, vasopressors, and dialysis at LT. METHODS: We identified adult eACLF-3 LT recipients between January 2010 and December 2021. Pre-LT characteristics were compared among eACLF-3 recipients with and without the futile outcome (1-year or in-hospital mortality), predictors of futility were identified, and a logistic regression model was evaluated using fivefold cross-validation. Findings were validated using the Multi-Organ Dysfunction and Evaluation for Liver Transplantation (MODEL) Consortium. RESULTS: ratio (OR = 3.9, p = 0.008), and pre-LT base deficit (OR = 1.27, p = 0.007). Futility was predicted with an AUROC of 0.74 (SD 0.15). When compared with the MODEL Consortium, our cohort had improved 3-, 6-, and 12-month survivals of 89%, 85%, and 80%, compared with 83%, 79%, and 70%, respectively (p = 0.048); however overall 5-year survival was similar (63% vs. 59%, p = 0.14). CONCLUSIONS: We report the largest single-center experience of LT for patients with eACLF-3, demonstrating acceptable survival despite high acuity, validated in the MODEL Consortium dataset. Prospective validation of the predictive model and identified risk factors is necessary, and may aid in appropriate selection of patients with ACLF-3 requiring maximal life support before LT. IMPACT AND IMPLICATIONS: There has been persistent interest in the liver transplant community regarding transplant for acute-on-chronic liver failure grade 3 (ACLF-3) recipients. In this work, we report on a large single-center experience transplanting ACLF-3 recipients, specifically investigating an extreme subset of these patients who were all mechanically ventilated, receiving vasopressors, and receiving hemodialysis at time of transplant. We characterized their outcomes, identifying clear risk factors associated with futility in this hyperacute subgroup and demonstrating that with appropriate selection, even patients in this extreme subgroup can experience acceptable 5-year post-transplant survival. Although we could not externally validate our model because of data availability, the obtained external patient cohort of patients with extreme ACLF-3 broadly validates our findings. We feel that these results represent an important contribution to the liver transplant community given concerns about transplanting this hyperacute subpopulation. These results may help guide physicians in selecting appropriate candidates for transplant.
Source: JHEP Reports
Authors: Andrew Melehy, Asara Thepbunchonchai, Benjamin V. Tran, Ruben Hernaez, Dominic Amara, Samer Ebaid, Daniela Markovic, Fady M. Kaldas, Igor Barjaktarevic, Victor Xia, Constantine J. Karvellas, Saro Khemichian, Lance L. Stein, Kirti Shetty, Christina C. Lindenmeyer, Justin R. Boike, Douglas A. Simonetto, Robert S. Rahimi, Prasun K. Jalal, Manhal Izzy, Michael S. Kriss, Gene Y. Im, Ming V. Lin, Janice H. Jou, Brett E. Fortune, George Cholankeril, Alexander Kuo, Vinay Sundaram, Atef Al Attar, Kambiz Kosari, Richard Garcia, Gevork Salmastyan, William Cranford, Preet Patel, Pei Xue, Soumya Mishra, Madison Parks, Gianina Flocco, Jing Gao, Tiffany Wu, Priya Thanneeru, Vikrant Reddy, Jing Gao, Mariana Hurtado, Islam Mohamed, Ross Vyhmeister, Christine R. Lopez, Braidie Campbell, Adam C. Winters, Mary Ann Simpson, Ronald W. Busuttil, Douglas G. Farmer, Vatche G. Agopian
Institutions: University of California, Los Angeles, Michael E. DeBakey VA Medical Center, Baylor College of Medicine, University of Alberta, University of Southern California, Keck Hospital of USC, Piedmont Atlanta Hospital, University of Maryland, Baltimore, Cleveland Clinic, Northwestern University, Mayo Clinic, Baylor University Medical Center, Vanderbilt University, University of Colorado Anschutz, Mount Sinai Hospital, Icahn School of Medicine at Mount Sinai, Lahey Hospital and Medical Center, Lahey Medical Center, Oregon Health & Science University, Montefiore Medical Center, Montefiore Health System, Cedars-Sinai Medical Center
Language: English
Subfield: Hepatology
Field: Medicine
Domain: Health Sciences
Open Access status: gold
Estimated APC paid: $4,110
OpenAlex ID: W7172484722