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

Abstract

OBJECTIVE 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). SUMMARY BACKGROUND DATA Limited data exist comparing LDLT and DDLT outcomes in ACLF, particularly addressing waitlist mortality. METHODS Retrospective analysis of all ACLF patients listed for transplant (2008-2023). Patients with living donors were categorized as intention-to-treat LDLT (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 complication and long-term survival. RESULTS 270 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 vs. 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 grade 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. CONCLUSION ITT-LDLT improved ITT-OS especially in ACLF grade 2/3 cohort and provided similar perioperative and long-term outcomes to DDLT.