Effect of the clinical course of acute-on-chronic liver failure prior to liver transplantation on post-transplant survival

[Display omitted] •Improvement of ACLF-3 prior to transplantation improves the probability of 1-year post-LT survival from 82.0% to 88.2%•Patients aged >60 years have a post-LT survival probability of 74.9% if transplanted with ACLF-3.•This post-LT survival probability rises to 82.7% if patients are transplanted with ACLF 0–2.•Improvement in brain and circulatory failure and removal from mechanical ventilation are associated with post-LT survival. Patients with acute-on-chronic liver failure (ACLF) can be listed for liver transplantation (LT) because LT is the only curative treatment option. We evaluated whether the clinical course of ACLF, particularly ACLF-3, between the time of listing and LT affects 1-year post-transplant survival. We identified patients from the United Network for Organ Sharing database who were transplanted within 28 days of listing and categorized them by ACLF grade at waitlist registration and LT, according to the EASL-CLIF definition. A total of 3,636 patients listed with ACLF-3 underwent LT within 28 days. Among those transplanted, 892 (24.5%) recovered to no ACLF or ACLF grade 1 or 2 (ACLF 0–2) and 2,744 (75.5%) had ACLF-3 at transplantation. One-year survival was 82.0% among those transplanted with ACLF-3 vs. 88.2% among those improving to ACLF 0–2 (p 60 years of age. Liver transplantation (LT) for patients with acute-on-chronic liver failure grade 3 (ACLF-3) significantly improves survival, but 1-year survival probability afte