Evaluation of available scoring systems in liver transplantation for severe acute-on-chronic liver failure (ACLF)
Abstract
Background & aims: The Transplantation for ACLF-3 Model (TAM) and Sundaram ACLF-LT-Mortality score (SALT-M) have been proposed to help select liver transplantation (LT) candidates with Acute-on-Chronic Liver Failure (ACLF) to optimize post-LT outcomes. We assessed the performance and clinical utility of these scores and their components on a large retrospective international multicenter study. Approach & results: All patients transplanted in the context of ACLF grade 3 (n=336) from nine international cohorts (2008-2024) were included in the study. The primary endpoint was 1-year post-LT survival. Score discrimination, calibration, and clinical utility using decision-curve (net benefit) analysis were assessed. The 1-year post-LT survival rate was 75.3%. Both TAM (OR 1.91, p=0.0001) and SALT-M (OR 1.09, p<0.0001) were associated with 1-year mortality but showed only modest discriminative performance (AUROC 0.61 and 0.64, respectively). Clinically relevant candidate high-risk thresholds were identified: TAM ≥3 (1-year survival 42.9% vs. 79.0%) and SALT-M >25 (46.9% vs. 78.7%). Respiratory failure (PaO₂/FiO₂ ≤200) was associated with 1-year post-LT mortality, whereas other variables included in the original scores, diabetes, BMI, and leukocyte count, did not demonstrate significant prognostic value in this cohort. Conclusions: In this large multicenter study, TAM and SALT-M were associated with post-LT mortality but demonstrated limited discriminative accuracy. Candidate high-risk thresholds (TAM ≥3, SALT-M >25) may help identify a small subset of patients with markedly poor post-LT outcomes. However, given their modest performance, these scores should support, not replace, multidisciplinary decision-making and their applicability should be evaluated in a prospective fashion.
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BibTeX
@article{lhermite2026evaluation,
title = {{Evaluation of available scoring systems in liver transplantation for severe acute-on-chronic liver failure (ACLF)}},
author = {Sébastien L’hermite and Isaure Breteau and Sebastien Halter and Nicolas Jacquinot and Valentin Coirier and José Ursic-Bedoya and Giovanni Perricone and Laure Elkrief and Philippe Ichai and Audrey Coilly and Sophie-Caroline Sacleux and Pauline Houssel‐debry and Baptiste Giguet and Line Carolle Ntandja Wandji and Alexandre Louvet and Filomena Conti and Edouard Bardou-Jacquet and Georges-Philippe Pageaux and Antoine Monsel and Eric Levesque and Constantine J. Karvellas and Jean-François Morcet and William Bernal and Florent Artru},
journal = {Liver Transplantation},
year = {2026},
month = sep,
doi = {10.1097/lvt.0000000000000987},
url = {https://hal.science/hal-05754643v1},
note = {CC BY-NC-ND 4.0},
}
RIS
TY - JOUR
TI - Evaluation of available scoring systems in liver transplantation for severe acute-on-chronic liver failure (ACLF)
AU - Sébastien L’hermite
AU - Isaure Breteau
AU - Sebastien Halter
AU - Nicolas Jacquinot
AU - Valentin Coirier
AU - José Ursic-Bedoya
AU - Giovanni Perricone
AU - Laure Elkrief
AU - Philippe Ichai
AU - Audrey Coilly
AU - Sophie-Caroline Sacleux
AU - Pauline Houssel‐debry
AU - Baptiste Giguet
AU - Line Carolle Ntandja Wandji
AU - Alexandre Louvet
AU - Filomena Conti
AU - Edouard Bardou-Jacquet
AU - Georges-Philippe Pageaux
AU - Antoine Monsel
AU - Eric Levesque
AU - Constantine J. Karvellas
AU - Jean-François Morcet
AU - William Bernal
AU - Florent Artru
PY - 2026
DA - 2026/09/08
JO - Liver Transplantation
DO - 10.1097/lvt.0000000000000987
UR - https://hal.science/hal-05754643v1
AB - Background & aims: The Transplantation for ACLF-3 Model (TAM) and Sundaram ACLF-LT-Mortality score (SALT-M) have been proposed to help select liver transplantation (LT) candidates with Acute-on-Chronic Liver Failure (ACLF) to optimize post-LT outcomes. We assessed the performance and clinical utility of these scores and their components on a large retrospective international multicenter study. Approach & results: All patients transplanted in the context of ACLF grade 3 (n=336) from nine international cohorts (2008-2024) were included in the study. The primary endpoint was 1-year post-LT survival. Score discrimination, calibration, and clinical utility using decision-curve (net benefit) analysis were assessed. The 1-year post-LT survival rate was 75.3%. Both TAM (OR 1.91, p=0.0001) and SALT-M (OR 1.09, p<0.0001) were associated with 1-year mortality but showed only modest discriminative performance (AUROC 0.61 and 0.64, respectively). Clinically relevant candidate high-risk thresholds were identified: TAM ≥3 (1-year survival 42.9% vs. 79.0%) and SALT-M >25 (46.9% vs. 78.7%). Respiratory failure (PaO₂/FiO₂ ≤200) was associated with 1-year post-LT mortality, whereas other variables included in the original scores, diabetes, BMI, and leukocyte count, did not demonstrate significant prognostic value in this cohort. Conclusions: In this large multicenter study, TAM and SALT-M were associated with post-LT mortality but demonstrated limited discriminative accuracy. Candidate high-risk thresholds (TAM ≥3, SALT-M >25) may help identify a small subset of patients with markedly poor post-LT outcomes. However, given their modest performance, these scores should support, not replace, multidisciplinary decision-making and their applicability should be evaluated in a prospective fashion.
SN - 1527-6465
SN - 1527-6473
ER -