One-year transplant-free survival following hospital discharge after ICU Admission for ACLF in the Netherlands

Background & AimsPatients with acute decompensated (AD) liver cirrhosis or acute-on-chronic liver failure (ACLF) often require intensive care unit (ICU) admission for organ support. Existing research, mostly from specialized liver transplant centers, largely addresses short-term outcomes. Our aim was to evaluate in-hospital mortality and 1-year transplant-free survival after hospital discharge in the Netherlands.MethodsWe conducted a nationwide observational cohort study, including patients with an history of cirrhosis or first complications of cirrhotic portal hypertension admitted to ICUs in the Netherlands between 2012 and 2020. The influence of ACLF grade at ICU admission on 1-year transplant-free survival after hospital discharge among hospital survivors was evaluated using unadjusted Kaplan-Meier (KM) survival curve and adjusted Cox proportional hazard model.ResultsOut of the 3,035 patients, 1,819 (59.9%) had ACLF grade 3. 1420 patients (46.8%) survived hospitalization after ICU admission. The overall probability of 1-year transplant-free survival after hospital discharge was 0.61 (95% CI 0.59-0.64). This rate varied with ACLF grade at ICU admission, being highest in patients without ACLF (0.71 [95% CI 0.66-0.76]) and lowest in those with ACLF-3 (0.53 [95% CI 0.49-0.58]) (Logrank P < 0.0001). However, after adjusting for age, malignancy status and MELD-score, ACLF grade at ICU admission was not associated with an increased risk of liver transplantation or death within one year after hospital discharge.ConclusionIn this nationwide cohort study, ACLF grade at ICU admission did not independently affect 1-year transplant-free survival after hospital discharge. Instead, age, presence of malignancy and the severity of liver disease played a more prominent role in influencing transplant-free survival after hospital discharge.Impact and implicationsPatients with Acute-on-chronic liver failure (ACLF) often require intensive care unit (ICU) admission for organ support. In these patients' short-term mortality is high, but long-term outcomes of survivors remain unknown. Using a large nationwide cohort of ICU patients, we discovered that the severity of ACLF at ICU admission does not influence one-year transplant-free survival after hospital discharge. Instead, age, malignancy status and overall severity of liver disease are more critical factors in determining their long-term survival.