Living Donor Liver Transplantation Reduced Waitlist Mortality in Acute-on-chronic Liver Failure

To compare intention-to-treat (ITT) and post-transplant outcomes of living donor liver transplant (LDLT) and deceased donor liver transplant (DDLT) in patients with acute-on-chronic liver failure (ACLF).

Limited data exist comparing LDLT and DDLT outcomes in ACLF, particularly addressing waitlist mortality.

Retrospective analysis of all ACLF patients listed for transplant (2008-2023). Patients with living donors were categorized as ITT-LDLT group and others as ITT-DDLT group. Primary outcome was to compare ITT-overall survival (ITT-OS), defined as survival from listing to death. Secondary outcomes included waitlist outcomes, post-transplant complications, and long-term survival.

Two hundred seventy patients were accepted for transplant (ITT-LDLT n=127, ITT-DDLT n=143) with similar clinical characteristics at listing. ITT-LDLT achieved superior ITT-OS, with 92.9% survival at 3 months versus 67.1% for ITT-DDLT ( P <0.001), driven by higher transplant rates (94.5% vs 53.8%, P <0.001) and shorter waiting times. ACLF grade 2 and 3 patients had the greatest survival benefit in ITT analysis. Futile waitlist outcomes, defined as death or delisting were more common in ITT-DDLT (4.7% vs 35.7%, P <0.001). Post-transplant outcomes were comparable; 30-day mortality (2.0% vs 1.0%, P =0.62), severe complication (28.6% vs 33.3%, P =0.47), and 5-year survival (74.5% vs 74.7%, P =0.46). Even for ACLF grades 2 and 3, LDLT achieved a 5-year survival at 87.2% and 68.0%, respectively. Older age, higher ACLF grade and ITT-DDLT predicted waitlist futility. Neither ACLF grades nor transplant type predicted graft survival.

ITT-LDLT improved ITT-OS, especially in ACLF grade 2/3 cohort, and provided similar perioperative and long-term outcomes to DDLT.