Urgent liver transplantation for acute-on-chronic liver failure in national data: Impact of dynamic MELD change and donor type on survival.

초록

Background/Aims: Acute-on-chronic liver failure (ACLF) carries high short-term mortality without liver transplantation (LT). This study compared outcomes between living-donor (LDLT) and deceased-donor liver transplantation (DDLT) for ACLF patients and evaluated dynamic MELD score changes as prognostic indicators. Methods: We retrospectively analyzed 199 adult ACLF patients who underwent emergency LT between 2017 and 2021 using the national KONOS registry. Patients were stratified by ACLF grade (I–III) and donor type. Dynamic change in MELD score (ΔMELD > 10%) from listing to transplantation was examined as a prognostic marker. Survival analysis and multivariate regression were performed to identify risk factors for mortality. Results: Among 219 ACLF candidates, 199 underwent LT (LDLT = 167, DDLT = 32). Without LT, all ACLF grade III patients died. Overall survival was comparable between LDLT and DDLT for the entire cohort (p=0.866) and ACLF grade I (p=0.642). However, LDLT demonstrated superior survival for ACLF grade II (p=0.042) and III (p=0.036) patients. The mean waiting time was significantly shorter for LDLT (2.3 days) versus DDLT (4.1 days) in grade III patients. ΔMELD > 10% independently predicted mortality (adjusted OR = 2.50, 95% CI 1.14–5.52, P = 0.023). Fungal infection (OR = 2.41, P = 0.012), postoperative complications (OR = 2.42, P = 0.021), and longer ICU stay (OR = 1.03 per day, P < 0.001) were additional risk factors. Conclusions: Timely LDLT neutralizes the prognostic disadvantage of higher ACLF grades. A rising MELD (> 10%) before LT is a key dynamic predictor of mortality. LDLT provides survival equivalence across ACLF grades and superior outcomes for grades II-III compared to DDLT, likely due to shorter waiting times. Vigilant perioperative care and early LDLT are essential to optimize outcomes.