Posttransplant Biliary Complications in Acute-on-Chronic Liver Failure: A Single Center Study

Abstract

Objectives: Liver transplantation is the only curative treatment for end-stage liver disease. Biliary complications, such as strictures, bile leaks, and stones, occur in up to 25% of cases and are a major source of morbidity. Biliary complication rates have been shown to be increased in high-acuity liver transplants. Here, we assessed biliary complications at a single institution (University of Oklahoma Health, Oklahoma, USA), focusing on patients with acute-on-chronic liver failure.

Materials and methods: Our retrospective analysis included liver transplant recipients seen from July 1, 2020, to June 30, 2023; we compared outcomes between those with and without acute-on-chronic liver failure. Patients were followed for at least 1 year posttransplant.

Results: Among 116 included patients, 21 (18.1%) developed biliary complications. Complications included 7 biliary leaks and 15 biliary strictures requiring intervention. Of 56 patients (48%) with acute-on-chronic liver failure, 8 (14.2%) developed biliary complications, compared with 13 (21.7%) without acute-on-chronic liver failure. Cold ischemia time was significantly longer (P = .05) and Model for End-Stage Liver Disease scores were significantly lower (P = .03) in patients with versus without biliary complications. Patients with complications also had higher preoperative cannabis use (19% vs 5%; P = .05) and postoperative readmission rates (3.0 vs 1.0; P = .01) versus patients without biliary complications. One-year graft and patient survival rates were 95.7% and 95.7%, respectively.

Conclusions: Despite an almost 50% rate of acute-on-chronic liver failure in our cohort, 18.1% of patients had posttransplant biliary complications, similar to the literature. Remarkably, patients with acute-on-chronic liver failure experienced fewer biliary complications than those without, potentially because of a multidisciplinary team approach and the strategic use of adjunct treatments like plasma exchange and continuous renal replacement therapy. This highlights the critical role of comprehensive, individualized care in improving outcomes for transplant patients with high-risk of complications.