Clinical and pathological spectrum of disease severity among patients with acute liver failure (ALF) undergoing deceased donor liver transplantation.

Abstract

Background: Listing and transplanting patients with acute liver failure (ALF) is challenging, requiring rapid assessment of the likelihood of recovery. The availability of a large number of ALF liver explants, along with their clinical data, afforded an opportunity to retrospectively evaluate liver transplantation (LT) decision-making. We hypothesized that, with the benefit of hindsight, a small number of patients might have recovered without LT.

Methods: Three hundred liver explants from ALF patients of varying etiologies who had undergone liver transplantation over 22 years in the Acute Liver Failure Study Group registry were reviewed for histopathological features and degree of necrosis by a committee of eight hepato-pathologists. A second committee of eight experienced transplant hepatologists independently reviewed clinical data on these same 300 patients and retrospectively scored the likelihood that each patient required transplantation.

Results: Only three (1%) of those reviewed by the Clinical Committee were considered to 'Definitely' not require liver grafting while an additional 10 (3.3%) were deemed to possibly not require transplantation (Not Likely Group, N=13). There was no difference in the degree of necrosis in explants in these groups, when compared to the remaining Likely Group, N=287 (95.6%), except in acetaminophen (APAP)-associated ALF where the degree of necrosis was more uniformly graded as severe, correlating with need for transplantation.

Conclusion: Virtually every patient undergoing liver transplantation for ALF retrospectively appeared to need their transplant, based on expert clinical consensus review. Overall, there was poor correlation between clinical severity and apparent degree of necrosis seen in the 300 liver explants, except perhaps for APAP subjects.