Predictive Factors for Death on a Long Waiting List for Liver Transplantation after an Episode of Acute on Chronic Liver Failure

Introduction Acute on chronic liver failure (ACLF) occurs in the context of a systemic inflammatory response and is associated with a high short-term mortality rate, depending on the number of organ failures (CLIF-OF scoring system). Liver transplantation (LT) can provide the prospect of a definitive treatment and survival benefit in patients with a high risk of early death. Material and Methods 255 patients with liver cirrhosis included on the waiting list (WL) between 2015 and 2017 were analyzed. 26.8% of patients had ACLF while on WL (stage 1 – 11.4%, stage 2 -7.1% and stage 3- 7.3% according to EASL CLIF classification). 33.8% of patients were transplanted during this time period of follow-up. Mean MELD score at inclusion on WL was 14.9±5.7. Cox Proportional Hazard Model Survival Analysis was performed to identify predictive factors of death on the WL after an ACLF episode. Results 19.1% of patients died while on the WL. As risk factors for death while on the WL after and ACLF episode we identified: grade of ACLF while on the WL (HR=2.91, p<0.0001), MELD at inclusion (HR=1.07, p=0.01), MELD score at ACLF (HR=1.15, p<0.0001), INR >2.5 (HR=4.42, p=0.0002), total bilirubin >12mg/dL (HR=2.08, p=0.009), hepatic encephalopathy grade III-IV (HR=3.66, p=0.0002), respiratory failure (HR=5.09, p=0.0001), circulatory failure (HR=3.19, p=0.03), other type of infections while on the WL (excepting spontaneous bacterial peritonitis) (HR=8.21, p=0.001). LT was a protective factor for death (HR=0.05, p=0.005). Patient survival at 3 months on WL was: 97.5% without any ACLF episode, 78% after an episode of ACLF stage 1, 76.6% after ACLF stage 2 and 59.6% after ACLF stage 3 (p<0.0001). 30.3% of the patients with LT had an episode of ACLF prior to LT compared to 25.3% of patients with ACLF and without LT (p=0.41). Median time from an episode of ACLF to LT was 4.9months. There was no difference regarding 1 and respectively 12 months survival of patients with or without ACLF prior to LT (p=0.97). Conclusions Independent predictors of death on WL after an ACLF episode were grade of ACLF and MELD score at inclusion, while LT is a protective factor for death on the WL. Short term survival after LT is similar between patients with and without ACLF while on the WL.