Living Donor Liver Transplantation reduced Waitlist Mortality in Acute-on-chronic Liver Failure

Abstract

Objective: To compare intention-to-treat (ITT) and post-transplant outcomes of living donor liver transplant (LDLT) and deceased donor liver transplant (DDLT) in patients with acute-on-chronic liver failure (ACLF).

Summary background data: Limited data exist comparing LDLT and DDLT outcomes in ACLF, particularly addressing waitlist mortality.

Methods: Retrospective analysis of all ACLF patients listed for transplant (2008-2023). Patients with living donors were categorized as intention-to-treat LDLT (ITT-LDLT) group and others as ITT-DDLT group. Primary outcome was to compare ITT-overall survival (ITT-OS), defined as survival from listing to death. Secondary outcomes included waitlist outcomes, post-transplant complication and long-term survival.

Results: 270 patients were accepted for transplant (ITT-LDLT n=127, ITT-DDLT n=143) with similar clinical characteristics at listing. ITT-LDLT achieved superior ITT-OS, with 92.9% survival at 3 months vs. 67.1% for ITT-DDLT (P<0.001), driven by higher transplant rates (94.5% vs. 53.8%, P<0.001) and shorter waiting times. ACLF grade 2 and 3 patients had the greatest survival benefit in ITT analysis. Futile waitlist outcomes, defined as death or delisting were more common in ITT-DDLT (4.7% vs. 35.7%, P<0.001). Post-transplant outcomes were comparable; 30-day mortality (2.0% vs. 1.0%, P=0.62), severe complication (28.6% vs. 33.3%, P=0.47) and 5-year survival (74.5% vs. 74.7%, P=0.46). Even for ACLF grade 2 and 3, LDLT achieved a 5-year survival at 87.2% and 68.0% respectively. Older age, higher ACLF grade and ITT-DDLT predicted waitlist futility. Neither ACLF grades nor transplant type predicted graft survival.

Conclusion: ITT-LDLT improved ITT-OS especially in ACLF grade 2/3 cohort and provided similar perioperative and long-term outcomes to DDLT.

Keywords: acute-on-chronic liver failure; deceased donor liver transplant; liver transplant; living donor liver transplant; outcomes.