Long-term outcomes and temporal trends following liver transplantation for chronic liver disease in the intensive care unit

Abstract

Background & aims: Liver transplantation (LT) remains the definitive treatment for patients with end-stage chronic liver disease (CLD). However, those transplanted while in the intensive care unit (ICU) represent a high-risk population. Large-scale data on long-term prognosis in this group are limited. We aimed to assess long-term outcomes in patients with CLD undergoing LT from the ICU and to compare outcomes over time.

Methods: This retrospective cohort study used the French national transplant registry (CRISTAL). Adults with CLD who underwent LT from the ICU between 2008 and 2018 were included. Organ failures were defined according to EASL CLIF-OF criteria. Five-year survival and associated risk factors were analyzed and compared across four time periods (2008-2010, 2011-2013, 2014-2016, 2017-2018).

Results: Among 13,372 LTs performed in France during the study period, 9,686 were for CLD, of which 1,287 (13.2%) patients were in the ICU at the time of LT. Alcohol-related liver disease (50%) and viral hepatitis (16.1%) were the leading etiologies. Five-year survival was significantly lower in ICU patients compared with non-ICU patients (69.2% vs. 79.1%, p <0.0001). Among patients who survived the first post-transplant year, 5-year survival exceeded 83% and was comparable to that of patients with CLD transplanted outside the ICU. Survival by era showed no significant improvement (p = 0.28). Age (hazard ratio [HR] 1.03, p <0.0001), mechanical ventilation (HR 1.57, p = 0.0001) and French donor risk score (HR 1.05, 95% CI [1.02-1.09], p <0.001) were independent predictors of mortality.

Conclusion: Patients transplanted from the ICU have significantly lower long-term survival, primarily due to elevated early post-transplant mortality, with no observed improvement over time. Careful candidate evaluation and donor selection remain critical to improving outcomes in this high-risk population.ClinicalTrials.gov number NCT06636409.

Impact and implications: This large national cohort study provides a comprehensive evaluation of long-term outcomes in critically ill patients with cirrhosis undergoing liver transplantation while in the intensive care unit. Despite advances in transplant care over the past decade, we observed a persistent survival gap in this high-risk population, primarily driven by increased mortality within the first year after transplantation. Age, the need for mechanical ventilation, and donor-related factors were independently associated with this excess risk. We also found no significant improvement in outcomes over time. These results underscore the continued need for refined candidate selection and donor allocation strategies, taking into account age, pre-transplant clinical stability, and graft quality to optimize post-transplant survival.

Keywords: intensive care unit; liver transplantation; long-term mortality.

Graphical abstract

Fig. 1

Study flowchart of patients identified through CRISTAL database. CLD, chronic liver disease; ICU, intensive care unit.

Fig. 2

Survival probability by ICU status. (A) 5-year survival of patients with CLD according to ICU status at LT. (B) 5-year survival after LT among 1-year survivors (CLD non-ICU vs. CLD-ICU). CLD, chronic liver disease; ICU, intensive care unit; LT, liver transplantation. Kaplan-Meyer and Log-rank test were used, and significant was considered if p <0.005.

Fig. 3

Survival probability by time period of LT. (A) 5-year survival probability in CLD-ICU patients according to time period of LT. (B) 5-year survival probability in CLD-ICU patients among 1-year survivors according to time period of LT. CLD, chronic liver disease; ICU, intensive care unit; LT, liver transplantation. Kaplan-Meyer test and Log-Rank test were used, significant if p <0.05.