Outcomes of Liver Transplantation Among Patients Diagnosed With Acute-on-Chronic Liver Failure: A Single-Center Experience.

Background: Acute-on-chronic liver failure (ACLF) describes the rapid deterioration of liver function triggered by factors including alcohol consumption, infection(s), and exacerbation(s) of chronic liver disease, and is characterized by a persistent "cytokine storm." While liver transplantation is the most effective treatment, comprehensive data regarding patient outcomes are limited.

Methods: Clinical data from 187 patients, who underwent liver transplantation (excluding re-transplantations and acute liver failure) between 2009 and 2023, were analyzed in accordance with Japan's ACLF diagnostic criteria. Immunological analysis included a mixed lymphocyte reaction with carboxyfluorescein succinimidyl ester staining (CFSE-MLR).

Results: Among 171 patients, 13 had ACLF (grade 0, n = 6; grade 2, n = 5; grade 3, n = 2), and 158 had non-ACLF. Five-year survival rates for the ACLF and non-ACLF groups were similar regardless of ACLF severity. Patients with ACLF had higher preoperative Model for End-stage Liver Disease (ie, "MELD") scores and Child-Pugh scores, and higher rates of dialysis, renal dysfunction, and respiratory failure (P < .05). The graft rejection rate was higher in the ACLF group than that in the non-ACLF group, and the CFSE-MLR assay revealed significantly elevated CD8-positive T cell responses to donor antigens in the first week post-transplantation.

Conclusion: Patients with ACLF achieved favorable postoperative outcomes despite poor preoperative conditions. High mortality rates among patients with ACLF on transplant waitlists emphasize the importance of timely transplantation. The increased anti-donor immune response after transplantation suggests a role for the underlying cytokine storm and underscores the need for careful postoperative management.