Pre-liver transplant assessment of patients with acute-on-chronic liver failure: An international survey

BACKGROUND & AIMS: Liver transplantation (LT) is increasingly performed in the setting of acute-on-chronic liver failure (ACLF). In this context, pre-transplant evaluation must be completed rapidly while minimizing the risk of overlooking contraindications. We aimed to describe current practices for pre-transplant assessment in patients with ACLF. METHODS: We conducted a survey across 34 European LT centers (including 16 French) and 22 French non-LT centers to assess pre-transplant evaluation practices, focusing on cardiopulmonary, addiction, oncological, and nutritional assessments. Practices were compared across three clinical scenarios: outpatients (OutPat), hospitalized decompensated patients without ACLF (Hosp), and patients with ACLF admitted to intensive care units (ACLF-ICU). In parallel, we retrospectively evaluated post-transplant outcomes in patients with cirrhosis and severe ACLF transplanted in two high-volume centers. RESULTS: Fifty-three centers (96%) responded. Cardiological stress testing was reported in 2% of ACLF-ICU patients vs. 21% of OutPat (p = 0.002) vs. 17% of Hosp patients (p = 0.008). Coronary angiography following abnormal non-invasive testing was less frequently performed in ACLF (42%) than in OutPat (76%, p = 0.0004) or Hosp patients (66%, p = 0.01). Alcohol abstinence requirements were more often decided on a case-by-case basis in patients with ACLF (62%) than in OutPat or Hosp patients. Oncological screening, including colonoscopy and ear, nose, and throat consultation, was also less frequently performed in ACLF-ICU patients. Median time from assessment initiation to listing was 7 days in ACLF-ICU vs. 45 days in OutPat and 18 days in Hosp patients (both p <0.0001). In the retrospective cohort (n = 221), patients listed after ACLF onset had a higher 1-year incidence of cardiovascular events than those listed before ACLF onset (19% vs. 9%). CONCLUSIONS: In ACLF-ICU patients, pre-transplant evaluation is markedly abbreviated, with critical gaps-particularly in cardiological assessment-highlighting the need for dedicated, evidence-based guidelines. IMPACT AND IMPLICATIONS: We sent a questionnaire to centers with an expertise in the management of patients with ACLF to assess current practices in pre-transplant evaluation in patients with ACLF admitted to an intensive care unit, as compared with patients without (outpatients and patients hospitalized in a regular ward). According to the responses from 53 centers, cardiological stress test and coronary angiography were less commonly performed as part of the pre-transplant evaluation in patients with ACLF admitted to the ICU, as well as colonoscopy and ear, nose, and throat consultation. Median timeframe from pre-LT workup initiation to listing was 7 days in patients with ACLF admitted to the ICU, which was significantly shorter than in patients without ACLF. These results suggest that pre-transplant workup is abbreviated in patients with ACLF, and might have an impact on post-transplant outcome, especially cardiovascular complications. Further dedicated studies are needed to specifically address the relation between pre-transplant workup and post-LT complications in patients with ACLF.