Lebertransplantation beim akut-auf-chronischen Leberversagen

For critically ill patients with acute-on-chronic liver failure (ACLF), liver transplantation is the only curative treatment option. Contrary to mounting evidence, patients with more than two organ failures are still often not considered as candidates for liver transplantation.

Review of current scientific evidence for liver transplantation in ACLF, factors contributing to posttransplant survival in this subgroup of patients, impact of bacterial infections on outcome, and decision making in the setting of high-grade ACLF.

Analysis and discussion of current evidence from retrospective and prospective clinical studies, discussion of current treatment guidelines and expert consensus

Patients with grade 3 ACLF at time of liver transplantation can have similar 1 year survival rates after liver transplantation compared to patients transplanted with decompensated cirrhosis without ACLF. To achieve such excellent outcomes, careful patient selection is essential. Determinants like uncontrolled infections, higher recipient age or comorbidities like diabetes or significant cardiovascular disease can significantly impair outcome after liver transplantation in ACLF. In the setting of alcoholic hepatitis and concomitant ACLF, an exception to the 6‑month abstinence rule before listing for liver transplantation should be considered.

Critically ill patients with ACLF and no obvious contraindications should be rapidly referred to a transplant center for evaluation considering their significant short-term mortality and small transplant window.