Impact of acute-on-chronic liver failure on 90-day mortality following a first liver transplantation

Background: Acute-on-chronic liver failure (ACLF) is associated with a significant short-term mortality rate (23%-74%), depending on the number of organ failures. Some patients present with ACLF at the time of liver transplantation (LT). The aim of this study was to assess whether ACLF was also a prognostic factor after LT and, if applicable, to construct a score that could predict 90-day mortality. Methods: Three hundred and fifty cirrhotic patients, who underwent LT between January 2008 and December 2013, were enrolled. We used ACLF grades according to EASL-CLIF consortium criteria to categorize the cirrhotic patients. A propensity score was applied with an Inverse Probability Treatment Weighting in a Cox model. A predictive score of early mortality after LT was generated. Results: One hundred and forty patients (40%) met the criteria for ACLF. The overall mortality rate at 90 days post-transplant was 10.6% (37/350 patients). ACLF at the time of LT (HR: 5.78 [3.42-9.77], P<.001) was an independent predictor of 90-day mortality. Infection occurring during the month before LT, high recipient age and male recipient, the reason for LT and a female donor were also independent risk factors for early mortality. Using these factors, we have proposed a model to predict 90-day mortality after LT. Conclusions: LT is feasible in cirrhotic patients with ACLF. However, we have shown that ACLF is a significant and independent predictor of 90-day mortality. We propose a score that can identify candidate cirrhotic patients in whom LT might be associated with futile LT.