Evidence for and Against Liver Transplantation for Acute-on-Chronic Liver Failure

Liver transplantation for patients with acute-on-chronic liver failure (ACLF) is controversial. This article summarizes recent evidence for and against transplantation in ACLF.

Given the rising prevalence, high short-term mortality, and limited treatment options for ACLF, there is a clear survival benefit in transplanting this population. Multiple recent studies have demonstrated that survival outcomes at 1 year after transplant have improved to greater than 80%, due to growing clinical experience and an increasing body of literature to guide management. However, drawbacks to liver transplantation for these patients include difficulty in determining transplant futility and inferior non-survival outcomes, such as increased healthcare resource utilization and impaired long-term quality of life. Furthermore, lack of consensus on ACLF definition and heterogeneity of the patient population present challenges in incorporating ACLF into organ allocation policy.

For patients with ACLF, survival benefit and recent improvements in survival outcomes must be weighed against post-transplant futility and impaired short- and long-term non-survival outcomes.