Given these poor outcomes, concerns about futility of transplant and
organ utility arise. This study provides further clarity on the topic,
with a 90-day post-transplant survival of 66% in ACLF 3 patients
compared with 75% and 84.2% in ACLF 2 and 1, respectively (rela-
tive to non-ACLF recipients [90.8%]). More importantly, they identify
improvers have clearly lower risk (86.5% 90-day survival) and can be
easily clinically identifiable at the time of an organ offer. Non-impro-
vers are the subset of concern for poor outcomes (55.7% 90-day
survival) and this is where the challenge truly exists; where
beneficence meets utility.
Ensuring proper utilisation of organs is crucial given their ongo-
ing shortage. While the transplant community aims to provide
transplant options to everyone in need, we must also balance the
need for allocation of the scarce resource for the highest yield for
years of life saved. This study better identifies a subgroup of ACLF
patients where the 90-day survival is possibly too low to satisfy
the organ utility yield. Yet, this survival rate, albeit low, is much
better than that without transplant.
Thus, to the individual patient
the clear answer is transplant. To the transplant community,
responsible for guardianship of the organs, the situation is murky.
More studies like this are needed to provide better guidance.
Implementing prognostication scores for short term survival in
clinical practice can help strike the balance between patient benefit
and organ utilisation. Although “necessity is the mother of taking
chances,” in the current transplant environment, these chances need
to be calculated.
Declaration of personal and funding interests: None.
K. D. Watt
This article is linked to Huebener et al papers. To view these articles
visit https://doi.org/10.1111/apt.14627 and https://doi.org/10.
K. D. Watt
Division of Gastroenterology and Hepatology, Mayo Clinic,
Rochester, MN, USA
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Editorial: transplantation in the setting of acute-on-chronic
liver failure—calculating chances. Authors’ reply
Reports from liver units across the globe repeatedly and consistently
confirm acute-on-chronic liver failure (ACLF) as a highly prevalent
and utterly severe complication of chronic liver disease.
astating prognosis of ACLF patients with multiple organ failures ren-
ders liver transplantation as the decidedly best chance for survival in
eligible patients with advanced disease, despite markedly inferior
post-transplant survival rates when compared to non-ACLF liver
Given the increasing prevalence of advanced
chronic liver disease and persistent scarcity of liver grafts, a judicious
selection of eligible transplant recipients will remain a major
© 2018 John Wiley & Sons Ltd