title: Acute-on-chronic liver failure before liver transplantation: impact on posttransplant outcomes.
abstract: BACKGROUND
  Acute decompensation in patients with chronic liver disease, resulting from acute kidney injury and infections, leads to significant morbidity and mortality. It is unclear whether patients who develop acute-on-chronic liver failure (ACLF) have poor outcomes after liver transplantation.
  
  
  METHODS
  We performed a single-center retrospective cohort study of 332 patients to evaluate the effect of ACLF, defined as an acute rise in the Model for End-Stage Liver Disease score of more than 5 within 4 weeks before transplantation, on posttransplant outcomes including stage 4 chronic kidney disease, death, recurrent cirrhosis, or graft failure requiring retransplantation.
  
  
  CONCLUSIONS
  One hundred fifty-seven patients in the study had ACLF and 175 patients had no ACLF (non-ACLF) pretransplant. Thirty-four patients in the entire cohort received dual organs, 10 of them (29.4%) had ACLF. Seventy-six percent of the patients with ACLF had acute kidney injury as their reason for decompensation and 23.6% had an infection. Mean Model for End-Stage Liver Disease score at transplant was significantly different between the groups (ACLF 28.77 vs. non-ACLF 21.23, P<0.0001). A total of 16.6% of the patients achieved an estimated glomerular filtration rate (eGFR) less than 30 mL/min, 21% of patients died, 12.3% developed cirrhosis, and 7.5% received a second transplant. There was no difference in mean eGFR between the ACLF and non-ACLF cohorts at 3 years posttransplant (56.35 mL/min vs. 59.93 mL/min, respectively, P=0.27). On multivariate analysis, ACLF was not significantly associated with eGFR less than 30 mL/min, death, recurrent cirrhosis, or retransplantation when adjusted for potential confounders.
authors.affiliation: Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA 19104, USA.
authors.forename: Ranjeeta
authors.initials: R
authors.lastname: Bahirwani
authors.forename: Oren
authors.initials: O
authors.lastname: Shaked
authors.forename: Meenakshi
authors.initials: M
authors.lastname: Bewtra
authors.forename: Kimberly
authors.initials: K
authors.lastname: Forde
authors.forename: K Rajender
authors.initials: KR
authors.lastname: Reddy
mesh_terms: D015331:Cohort Studies; D058625:End Stage Liver Disease / Q000150:complications*; D005260:Female; D005919:Glomerular Filtration Rate; D006801:Humans; D017114:Liver Failure, Acute / Q000150:complications*; D016031:Liver Transplantation / Q000009:adverse effects* / Q000401:mortality; D008297:Male; D008875:Middle Aged; D012086:Reoperation; D012189:Retrospective Studies; D016896:Treatment Outcome