Access to liver transplantation for ACLF patients in a French center: initial trajectory matters.

Liver transplantation (LT) significantly improves prognosis of Acute-on-chronic Liver Failure (ACLF). To investigate the prognostic factors of ACLF patients referred to a LT-center, we retrospectively included 143 ACLF patients discussed for LT at a LT-center, collecting data on their clinical trajectories. The majority (57%) were referred by a non-LT center for an alcohol-related liver disease (73%). Of these patients, 40% underwent LT, 34% died on the waiting-list (D-WL) and 26% were denied for LT. The latter group had mainly been referred by a non-LT center (81%vs. 48% in the listed group), had more active alcohol use (68%vs. 23%) but no difference in initial disease severity. Transplanted patients were younger than D-WL patients and had fewer cardiovascular comorbidities whereas initial cares were comparable (30%vs 25% admitted directly at the LT center). Independent factors associated with a lower probability of listing were active alcohol use (0.19 [0.04-0.77]), age (0.13 [0.03-0.43]), early clinical deterioration (0.21 [0.06-0.65]) and initial care in non-LT centers (3.82 [1.23-13.7]). Age and cardiovascular history were independent factors for D-WL. In conclusion, in our center, the patients' initial management and alcohol consumption influenced their registration on WL, while death on the WL remained linked to clinical condition.