Pre-liver transplant assessment of patients with acute-on-chronic liver failure: an international survey
Abstract
Background and aims Liver transplantation (LT) is increasingly performed in the setting of acute-on-chronic liver failure (ACLF). In this context, pre-transplant evaluation must be completed rapidly while minimizing the risk of overlooking contraindications. We aimed to describe current practices for pre-transplant assessment in ACLF patients. Materials and 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 ACLF patients 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 noninvasive 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 ACLF (62%) than in OutPat or Hosp patients. Oncological screening, including colonoscopy and ENT consultation, was also less frequently performed in ACLF-ICU patients. Median time from assessment initiation to listing was 7 days in ACLF-ICU versus 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%). Conclusion 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 in intensive care unit, as compared to patients without (outpatients and patients hospitalized in regular ward) According to the responses from 53 centers, cardiological stress test and coronary angiography were less commonly performed as part as pre-transplant evaluation in patients with ACLF admitted to the ICU, as well as colonoscopy and Ear Nose 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.
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BibTeX
@article{bellec2026preliver,
title = {{Pre-liver transplant assessment of patients with acute-on-chronic liver failure: an international survey}},
author = {Claire Bellec and Anea Augé and Sébastien L’hermite and Romain Moirand and Armand Abergel and Matthew Amstrong and Teresa Antonini and Rodolphe Anty and Marion Khaldi and Aurore Baron and Mouni Bensenane-Oussalah and William Bernal and Christophe Bureau and Nicolas Carbonell and Jean-François Cadranel and Filipe Cardoso and Paul Carrier and Audrey Coilly and Isabel Conde and Filomena Conti and Agnes Bonadona and Gonzalo Crespo and Sarwa Darwish Murad and Sébastien Dharancy and Christophe Duvoux and Cornelius Engelmann and François Faitot and Claire Francoz and Armand Garioud and René Gerolami and Elia Gigante and Odile Goria and Thierry Gustot and Brian Hogan and Ludovic Lagin and Adrien Lannes and Marianne Latournerie and Victor de Ledinghen and Giulia Magini and Martin Mateo and Arnaud Maurin and Manuela Merli and Magdalena Meszaros and Georges-Philippe Pageaux and Claire Perignon and Giovanni Perricone and Michael Praktiknjo and Noemi Reboux and Thomas Reiberger and Valentin Rolle and Isabelle Rosa and Ruxandra Sarba and Faustine Wartel and Delphine Verhoeven Weil and Alberto Zanetto and Laure Elkrief and Florent Artru},
journal = {JHEP Reports Innovation in Hepatology},
year = {2026},
month = oct,
doi = {10.1016/j.jhepr.2026.101794},
url = {https://hal.science/hal-05549742v1},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Pre-liver transplant assessment of patients with acute-on-chronic liver failure: an international survey
AU - Claire Bellec
AU - Anea Augé
AU - Sébastien L’hermite
AU - Romain Moirand
AU - Armand Abergel
AU - Matthew Amstrong
AU - Teresa Antonini
AU - Rodolphe Anty
AU - Marion Khaldi
AU - Aurore Baron
AU - Mouni Bensenane-Oussalah
AU - William Bernal
AU - Christophe Bureau
AU - Nicolas Carbonell
AU - Jean-François Cadranel
AU - Filipe Cardoso
AU - Paul Carrier
AU - Audrey Coilly
AU - Isabel Conde
AU - Filomena Conti
AU - Agnes Bonadona
AU - Gonzalo Crespo
AU - Sarwa Darwish Murad
AU - Sébastien Dharancy
AU - Christophe Duvoux
AU - Cornelius Engelmann
AU - François Faitot
AU - Claire Francoz
AU - Armand Garioud
AU - René Gerolami
AU - Elia Gigante
AU - Odile Goria
AU - Thierry Gustot
AU - Brian Hogan
AU - Ludovic Lagin
AU - Adrien Lannes
AU - Marianne Latournerie
AU - Victor de Ledinghen
AU - Giulia Magini
AU - Martin Mateo
AU - Arnaud Maurin
AU - Manuela Merli
AU - Magdalena Meszaros
AU - Georges-Philippe Pageaux
AU - Claire Perignon
AU - Giovanni Perricone
AU - Michael Praktiknjo
AU - Noemi Reboux
AU - Thomas Reiberger
AU - Valentin Rolle
AU - Isabelle Rosa
AU - Ruxandra Sarba
AU - Faustine Wartel
AU - Delphine Verhoeven Weil
AU - Alberto Zanetto
AU - Laure Elkrief
AU - Florent Artru
PY - 2026
DA - 2026/10/13
JO - JHEP Reports Innovation in Hepatology
DO - 10.1016/j.jhepr.2026.101794
UR - https://hal.science/hal-05549742v1
AB - Background and aims Liver transplantation (LT) is increasingly performed in the setting of acute-on-chronic liver failure (ACLF). In this context, pre-transplant evaluation must be completed rapidly while minimizing the risk of overlooking contraindications. We aimed to describe current practices for pre-transplant assessment in ACLF patients. Materials and 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 ACLF patients 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 noninvasive 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 ACLF (62%) than in OutPat or Hosp patients. Oncological screening, including colonoscopy and ENT consultation, was also less frequently performed in ACLF-ICU patients. Median time from assessment initiation to listing was 7 days in ACLF-ICU versus 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%). Conclusion 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 in intensive care unit, as compared to patients without (outpatients and patients hospitalized in regular ward) According to the responses from 53 centers, cardiological stress test and coronary angiography were less commonly performed as part as pre-transplant evaluation in patients with ACLF admitted to the ICU, as well as colonoscopy and Ear Nose 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.
SN - 2589-5559
ER -