Survival With and Without Liver Transplantation in Critically Ill Patients With Cirrhosis: A 20-Year Experience

In 2015, we reported the outcome of patients with cirrhotic chronic liver disease with unplanned admission to a specialist single-center Liver Intensive Therapy Unit (LITU) demonstrating progressive improvement in short-term survival. We investigated if this and long-term survival had continued to improve, and its relation to use and outcome of liver transplantation (LT).

A retrospective cohort study of consecutive adult patients with cirrhosis and unplanned emergent first LITU admission January 2000 to March 2020. Demographic and clinical variables were obtained at admission; acute-on-chronic liver failure (ACLF) grade was categorized as 0 (no ACLF), 1 or 2, or 3. Transplant-free survival (TFS) and LT practices were characterized and survival compared using time-to-event analysis.

The cohort comprised 1688 patients (62% male; median age 52 years [interquartile range, 43-60 years]) with Model for End-Stage Liver Disease score 28 (interquartile range, 18-37); 23% had no ACLF, 39% had ACLF 1 or 2, and 37% had ACLF 3; TFS closely related to ACLF grade (P < .001). LITU TFS was 51.9% in 2000 to 2009, increasing to 70.6% in 2010 to 2020 (P < .001); improvement for ACLF 3 was smaller: 31.0% to 45.8%, (P < .001). There was no difference in TFS survival in 2010 to 2014 vs 2015 to 2020. Long-term TFS was poor with <20% of patients alive without LT 1 year after LITU admission. During follow-up, 280 underwent LT: the proportion transplanted increased from 12.6% in 2000 to 2009 to 20.2% in 2010 to 2020, with 1- and 5-year post-transplant survival of 91% and 81.9%.

TFS has now plateaued with need for novel interventions to improve survival in ACLF. LT is infrequently utilized but has excellent outcomes. ACLF survivors should be closely followed up with strong consideration given for transplant assessment.