(394) Outcomes of Acute Liver Failure Patients Not Listed for Liver Transplantation: A Cohort Analysis

Introduction: Acute liver failure (ALF) is a rare condition leading to intensive care unit admission and significant morbidity and mortality. Liver transplantation (LT) is often required as a life saving measure. However patients are not always listed for LT and there is lack of data around the outcomes of such patients. Our aim is to describe outcomes of ALF patients not listed for LT and identify factors associated with death at 21 days.

Methods: Retrospective analysis of all ALF patients not listed for LT enrolled in the US Acute Liver Failure Study Group (US-ALFSG) registry between 1998 and 2018. Primary outcome was death at 21 days. Patients deceased at 21 days were compared to those alive at 21 days. Multivariable logistic regression was done to identify factors associated with death at 21 days.

Results: 1672 ALF patients were not listed for LT. Median age was 41 [Interquartile Range (IQR) 30-54] and 527 (31.5%) were male. 371 (28.9%) patients were too sick to list. Most common etiology was acetaminophen toxicity (54.8%). 330 (19.7%) patients met King’s College Criteria (KCC) for LT. Median ALFSG Prognostic Index (ALFSG-PI) was 38% (IQR 13.2%-71.5%) chance of spontaneous survival. 951 (56.9%) patients required mechanical ventilation, 564 (33.7%) needed vasopressors, and 246 (14.7%) required continuous renal replacement therapy (CRRT). 558 (35.7%) patients died at 21 days. Compared to those who survived, patients who died were more likely to be too sick for listing (56.8% vs 15.5%), have a non-acetaminophen etiology (62.7% vs 36.9%), fulfil KCC (41.4% vs 9.2%), have lower ALFSG-PI (11.4% vs 53.9%), need mechanical ventilation (78.9% vs 46.2%), need vasopressors (61.6% vs 19.5%), and need CRRT (20.3% vs 13%) (p < 0.05 for all). After adjusting for relevant covariates, age [adjusted odds ratio (aOR) 1.03, 95% confidence interval (CI) 1.02-1.04], KCC (aOR 3.17, CI 2.23-4.51), grade 3/4 encephalopathy (aOR 1.83, CI 1.18-2.83), mechanical ventilation (aOR 1.53, CI 1.01-2.33), and vasopressors (aOR 2.10, CI 1.43-3.08) (p < 0.05 for all) were all independently associated with death at 21 days.

Conclusions: Despite no LT, majority of patients were still alive at 21 days. Multiorgan failure resulting in grade 3/4 encephalopathy, need for mechanical ventilation, and need for vasopressors lead to poor prognosis.