JOURNAL OF HEPATOLOGY
Editorial
Liver transplantation in patients with ACLF and multiple organ failure: Time for priority after initial stabilization Javier Fernández1,2,3,4, Faouzi Saliba5,6,7,⇑ 1
Liver ICU, Liver Unit, Hospital Clínic, University of Barcelona, Barcelona, Catalonia, Spain; 2Institut d’Investigacions Biomèdiques August-Pi-Sunyer (IDIBAPS), Spain; 3Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBEREHED), Spain; 4 European Foundation of Chronic Liver Failure (EF-Clif), Barcelona, Spain; 5AP-HP, Hôpital Paul Brousse, Centre Hépato-Biliaire, Villejuif, France; 6Université Paris Sud and University Paris Saclay, Paris XI, France; 7Unité INSERM U 935 and U 1193, Villejuif, France See Article, pages 1047–1056
Short-term prognosis of cirrhotic patients with acute-onchronic liver failure (ACLF) and multiple organ failure (MOF) is extremely poor in the absence of salvage liver transplantation (LT). Mortality correlates with the number of organ failures defined by the CLIF sequential organ failure assessment score and based on the CLIF-organ failure scoring system, reaching more than 80% at 30 days in patients with three or more organ failures even with unrestricted ICU support.1–4 The role of LT in these patients remains controversial. While LT solves liver failure, a key prognostic determinant of ACLF course,4 coagulation, cerebral and functional renal failure (hepatorenal syndrome), its impact on the reversion of other extrahepatic organ failures and on survival is unclear.5 In this setting and considering the scarcity of liver donors, many centers contraindicate transplantation in these very sick patients. While these patients could benefit, in relation to their high model for end-stage liver disease (MELD) score, from rapid access to transplant, LT is considered futile because of the presumed low survival rates after surgery; the patient is considered ‘‘too sick to be transplanted”.5–7 Several reports show encouraging results for LT in ACLF, using living or deceased donors.8–10 However, limited and conflicting data are available on the results of LT in the worst clinical scenario: patients with ACLF and MOF (three or more organ failures). In a single center retrospective study, Umgelter et al. reported poor outcomes in a small series of 13 patients with ACLF-3 undergoing LT. All were treated with vasopressors and mechanical ventilation and 77% by renal replacement therapy.11 Ninety day and one-year survival rates were 62% and 46%, respectively, figures that are below the threshold classically accepted (>50% expectancy of five-year survival post-LT). Remarkably, patients who survived showed shorter ICU stay before LT than those who died (8 days compared to 32), a finding that suggests that timely LT could be essential to effectively attain good survival rates in this very sick population. Another small retrospective study reported very unfavorable outcomes in 30 ACLF-3 patients after LT with a one-year survival rate of just 43.3%.12 Many of these patients were transplanted with q
DOI of original article: http://dx.doi.org/10.1016/j.jhep.2018.07.007. Corresponding author. Address: Pr Faouzi SALIBA, Hôpital Paul Brousse, Centre Hépato-Biliaire, 12 avenue Paul Vaillant Couturier, 94800 Villejuif, France. Tel.: +33 1 4559 64 12; fax: +33 1 4559 38 57. E-mail address:
[email protected] (F. Saliba). ⇑
lung and circulatory failure (76.6% and 60%, respectively) and 70% were infected before LT. The time to LT from ACLF diagnosis, doses of vasopressors and PaO2/FiO2 ratio were not described. In contrast, recent studies suggest that salvage LT is feasible and associated with a clear survival benefit in selected patients with ACLF grade 3 or more. In the Canonic study, 25 patients with ACLF were transplanted during the 28-day follow-up, 38% of them had ACLF-3.4 None of the patients were transplanted with respiratory failure (PaO2/FiO2 ratio 3 mg/h (equivalent to 0.6 lg/kg/min) and severe acute respiratory distress syndrome (PaO2/FiO2 ratio
