Heterogeneity in liver transplantation practices for critically ill patients with chronic liver disease in the U.S

Liver transplantation (LT) in critically ill patients with chronic liver disease is a high-risk procedure. Recent studies show that the frequency of intensive care unit (ICU) LTs has risen, and outcomes of such transplants have improved significantly. Variation in practices and the impact of center experience with ICU LTs on outcomes is unknown outside of acute liver failure (ALF). This study evaluated the impact of center experience with ICU LT on outcome metrics. Using the United Network for Organ Sharing database, we conducted a retrospective analysis of adult liver transplants performed 2014-2023 in which the patient was in an ICU before transplant, excluding those listed for multiorgan, retransplant, or ALF. Critical care requirements, in-hospital, 1-year, and 3-year mortality, and retransplant were compared by center ICU LT volume quartiles. In total, 9542 ICU LTs were performed across 130 centers (12.8% of total LTs). Over half of U.S. centers performed fewer than 5 ICU LTs per year on average, while the centers in the highest quartile performed nearly two-thirds of all ICU LTs in this period. Utilization of dialysis and of concurrent critical care therapies in ICU LT recipients was higher at high-volume centers ( p <0.05). In-hospital, 1-year, and 3-year mortality for ICU LTs overall were 6.2%, 10.4%, and 23.1%, respectively, with no differences across center volume quartiles (all p >0.05). Adjusting for severity of illness, center volume of ICU LTs in the prior year was associated with a small but significant reduction in 1-year post-ICU LT mortality: aOR 0.96 per 5 ICU LTs ( p <0.001). Expansion of LT for ICU candidates does not appear to threaten center-based metrics and may even offer important benefits to future candidates.