Outcomes of patients with acute liver failure listed for liver transplantation: A multicenter prospective cohort analysis

Constantine J. Karvellas, Thomas M. Leventhal, Jorge L. Rakela, Jingwen Zhang, Valerie Durkalski, K. Rajender Reddy, Robert J. Fontana, R. Todd Stravitz, John R. Lake, William M. Lee, Justin R. Parekh

Research output: Contribution to journalArticlepeer-review

15 Scopus citations


Liver transplantation (LT) is a life-saving treatment for patients with acute liver failure (ALF). Currently, there are few detailed data regarding long-term outcomes after LT for ALF. We combined prospective data from the Acute Liver Failure Study Group (ALFSG) Registry with those of the Scientific Registry of Transplant Recipients (SRTR) to assess outcomes among consecutive patients with ALF listed for LT. Cohort analysis of detailed pretransplantation data for patients listed for LT for ALF in the ALFSG Registry between January 1998 and October 2018 matched with transplantation-related data from the SRTR. Primary outcomes were 1- and 3-year post-LT patient survival. Secondary outcome was receipt of LT; independent associations with successful receipt of LT were determined using multivariable logistic regression. Of 624 patients with ALF listed for LT, 398 (64%) underwent LT, 100 (16%) died without LT, and 126 (20%) recovered spontaneously. Among LT recipients, etiologies included seronegative/indeterminate (22%), drug-induced liver injury (18%), acetaminophen overdose (APAP; 16%), and viral hepatitis (15%). The 1- and 3-year post-LT patient survival rates were 91% and 90%, respectively. Comparing those dying on the waiting list versus with those who received LT, the former had more severe multiorgan failure, reflected by increased vasopressor use (65% vs. 22%), mechanical ventilation (84% vs. 57%), and renal replacement therapy (57% vs. 30%; p < 0.0001 for all). After adjusting for relevant covariates, age (adjusted odds ratio [aOR] 1.02, 95% confidence interval [CI] 1.00-1.04), APAP etiology (aOR 2.72, 95% CI 1.42-5.23), requirement for vasopressors (aOR 4.19, 95% CI 2.44-7.20), Grade III/IV hepatic encephalopathy (aOR 2.47, 95% CI 1.29-4.72), and Model for End-Stage Liver Disease (MELD) scores (aOR 1.05, 95% CI 1.02-1.09; p < 0.05 for all) were independently associated with death without receipt of LT. Post-LT outcomes for ALF are excellent in this cohort of very ill patients. The development of multiorgan failure while on the transplantation list and APAP ALF etiology were associated with a lower likelihood of successful receipt of LT.

Original languageEnglish (US)
Pages (from-to)318-330
Number of pages13
JournalLiver Transplantation
Issue number3
StatePublished - Mar 2023

Bibliographical note

Funding Information:
The study was sponsored by NIH grant U‐01 58369 (from NIDDK).

Funding Information:
John R. Lake is employed by Miromatrix. He consults for HepQuant. K. Rajender Reddy consults for and received grants from Mallinckrodt. He consults for Novo Nordisk, Spark Therapeutics, and GENFIT; received grants from BMS, Intercept, Exact Sciences, Sequana, Grifols, BioVie, HCC TARGET, and NASH TARGET. Robert J. Fontana received grants from Gilead. William M. Lee consults for Karuna, Forma, SenGen, Seal Rock, Pfizer, and GSK. He received grants from Eiger, Intercept, Gilead, Alexion, Cumberland, and IL.

Publisher Copyright:
© 2022 American Association for the Study of Liver Diseases.

PubMed: MeSH publication types

  • Multicenter Study
  • Journal Article
  • Research Support, N.I.H., Extramural


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