Pre-liver transplant assessment of patients with acute-on-chronic liver failure: An international survey.
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Bellec Claire, Augé Anea, L'Hermite Sébastien, Moirand Romain, Abergel Armand, Amstrong Matthew, Antonini Teresa, Anty Rodolphe, Khaldi Marion, Baron Aurore, Bensenane-Oussalah Mouni, Bernal William, Bureau Christophe, Carbonell Nicolas, Cadranel Jean-François, Cardoso Filipe, Carrier Paul, Coilly Audrey, Conde Isabel, Conti Filomena, Bonadona Agnes, Crespo Gonzalo, Murad Sarwa Darwish, Dharancy Sébastien, Duvoux Christophe, Engelmann Cornelius, Faitot François, Francoz Claire, Garioud Armand, Gerolami René, Gigante Elia, Goria Odile, Gustot Thierry, Hogan Brian, Lagin Ludovic, Lannes Adrien, Latournerie Marianne, de Ledinghen Victor, Magini Giulia, Mateo Martin, Maurin Arnaud, Merli Manuela, Meszaros Magdalena, Pageaux Georges-Philippe, Perignon Claire, Perricone Giovanni, Praktiknjo Michael, Reboux Noemi, Reiberger Thomas, Rolle Valentin, Rosa Isabelle, Sarba Ruxandra, Wartel Faustine, Weil Delphine Verhoeven, Zanetto Alberto, Elkrief Laure, Artru Florent
Аннотация
METHODS: We conducted a survey across 34 European LT centers (including 16 French) and 22 French non-LT centers to assess pre-transplant evaluation practices, focusing on cardiopulmonary, addiction, oncological, and nutritional assessments. Practices were compared across three clinical scenarios: outpatients (OutPat), hospitalized decompensated patients without ACLF (Hosp), and patients with ACLF admitted to intensive care units (ACLF-ICU). In parallel, we retrospectively evaluated post-transplant outcomes in patients with cirrhosis and severe ACLF transplanted in two high-volume centers.
RESULTS: Fifty-three centers (96%) responded. Cardiological stress testing was reported in 2% of ACLF-ICU patients vs. 21% of OutPat (p = 0.002) vs. 17% of Hosp patients (p = 0.008). Coronary angiography following abnormal non-invasive testing was less frequently performed in ACLF (42%) than in OutPat (76%, p = 0.0004) or Hosp patients (66%, p = 0.01). Alcohol abstinence requirements were more often decided on a case-by-case basis in patients with ACLF (62%) than in OutPat or Hosp patients. Oncological screening, including colonoscopy and ear, nose, and throat consultation, was also less frequently performed in ACLF-ICU patients. Median time from assessment initiation to listing was 7 days in ACLF-ICU vs. 45 days in OutPat and 18 days in Hosp patients (both p <0.0001). In the retrospective cohort (n = 221), patients listed after ACLF onset had a higher 1-year incidence of cardiovascular events than those listed before ACLF onset (19% vs. 9%).
CONCLUSIONS: In ACLF-ICU patients, pre-transplant evaluation is markedly abbreviated, with critical gaps-particularly in cardiological assessment-highlighting the need for dedicated, evidence-based guidelines.
IMPACT AND IMPLICATIONS: We sent a questionnaire to centers with an expertise in the management of patients with ACLF to assess current practices in pre-transplant evaluation in patients with ACLF admitted to an intensive care unit, as compared with patients without (outpatients and patients hospitalized in a regular ward). According to the responses from 53 centers, cardiological stress test and coronary angiography were less commonly performed as part of the pre-transplant evaluation in patients with ACLF admitted to the ICU, as well as colonoscopy and ear, nose, and throat consultation. Median timeframe from pre-LT workup initiation to listing was 7 days in patients with ACLF admitted to the ICU, which was significantly shorter than in patients without ACLF. These results suggest that pre-transplant workup is abbreviated in patients with ACLF, and might have an impact on post-transplant outcome, especially cardiovascular complications. Further dedicated studies are needed to specifically address the relation between pre-transplant workup and post-LT complications in patients with ACLF.