November 30, 2022 Perceptions and practices impact equity in access to liver transplantation for critically ill patients with cirrhosis A survey on the attitudes towards liver transplantation for patients with acute-on-chronic liver failure grade 3 (ACLF-3) reveals differences between countries and transplant centers.

BARCELONA—While liver transplantation is the most effective treatment available for patients with ACLF-3, access to liver transplantation for these critically ill patients with underlying cirrhosis and multiorgan failures varies greatly across countries and transplant centers in each country. Barriers to access to liver transplantation may include admission to the intensive care unit, referral to a tertiary hospital, timely organ allocation, and listing for liver transplant. Access to liver transplantation for patients with ACLF-3, although, requires agreement between all members of the transplant team, but also health professionals at primary and secondary centers should be aware of liver transplantation as potential treatment for patients with cirrhosis that require critical care.

Image: © European Foundation for the Study of Chronic Liver Failure.

In collaboration with the European Liver and Intestine Transplant Association (ELITA), an online questionnaire was designed to learn about actual obstacles to liver transplantation and current practice in transplant centers participating in the CHANCE study.

The study published on 5 November 2022 in Journal of Hepatology anonymously surveyed 1031 transplant doctors (including hepatologists, intensivists, anesthesiologists and surgeons) and the first 100 responses analyzed. The majority of respondents (65%) reported that fewer than 5 patients with ACLF-3 were transplanted in their center (with 58% of the respondents being residents of centers performing more than 50 liver transplantations per year).

Most respondents (66%) considered there is sufficient evidence in the literature to support liver transplantation in patients with ACLF-3, yet 70% of the respondents declared patients with ACLF-3 not having adequate access to liver transplantation. While a few respondents reported that colleagues at their own transplant center were hesitant to include critically ill patients with cirrhosis on the waiting list, most respondents identified physicians who referred patients to liver transplantation centers unwilling to transplant patients with ACLF-3. According to the survey, anesthesiologists and intensivists were the professional groups most unwilling to consider these patients for liver transplantation, followed by surgeons and hepatologists.

Some respondents (48) reported that the average time on waiting list in their center was too long for patients with ACLF-3 and the majority (58 respondents) agreed that prioritization of patients with ACLF-3 was not sufficient. Most respondents (82) claimed for evidence-based organ allocation strategies to yield improved equity in access to liver transplantation and exclude only those patients that are too sick at the time of listing.

The authors concluded that there are inconsistencies between the existing clinical evidence and current practice regarding access to liver transplantation for patients with ACLF-3 and called for a positive attitude towards critically ill patients with cirrhosis that would benefit from access to liver transplantation.

Publication information

Artzner, T., Belli, L.S.; Faitot, F., Jalan, R. Attitudes toward liver transplantation for ACLF-3 patients determine equity of access. J. Hepatol. 2022. DOI: 10.1016/j.jhep.2022.10.029

About CHANCE study

CHANCE is a multicenter, global, observational study designed to assess the benefit of liver transplantation in patients with acute-on-chronic liver failure (ACLF) grade 2 or grade 3. This study counts with the support of the International Liver Transplantation Society (ILTS) and the European Liver and Intestine Transplant Association (ELITA) to recruit 2000 patients in 80 centers in 27 countries around the world. The primary objective of the CHANCE study is to compare 1-year graft and patient survival rates after liver transplantation in patients with ACLF grade 2 or grade 3 at the time of liver transplantation with patients with decompensation of cirrhosis without ACLF-2 or 3 and transplant-free survival of patients with ACLF-2 or 3 not listed for liver transplantation. The international nature of this study will allow for deep assessments of the potential impact of different precipitating factors of ACLF (e.g., alcohol vs. Hepatitis B virus flare), different types of liver transplantation (deceased donor vs. living donor liver transplantation) and different regional and national allocation systems on transplant outcomes. Besides these clinical objectives, the CHANCE study aims to build a repository of biological samples to explore new biomarkers to predict prognosis on the waiting list and after liver transplantation, and mechanisms of liver and extrahepatic organ recovery. Identifier: NCT04613921


The European Foundation for the Study of Chronic Liver Failure (EF CLIF) is a private non-profit organization connecting biomedical researchers and healthcare professionals with each other, with patients and patient associations, and with society. The fundamental purpose of EF CLIF, reflected in its founding Statements of 2015, is to advance knowledge and promote research and education in liver disease to improve the prognosis of patients living with chronic liver failure.

The Foundation has made pioneering efforts in conducting a series of large, international prospective studies that have been instrumental in reclassifying the trajectory of patients with chronic liver failure and led to the clinical, prognostic and pathophysiological definition of the syndrome referred to as “acute-on-chronic liver failure” characterized by acute decompensation of cirrhosis, severe systemic inflammation, organ failures, and high short-term mortality. We are inspiring best clinical practices for the management of patients with chronic liver failure and promoting a more sustainable and equitable healthcare system.

Within the Foundation, the European Association for the Study of the Liver (EASL) Chair supports research activities through the EASL-CLIF Consortium, a network of 117 tertiary care and university hospitals in 28 European countries. The Grifols Chair promotes translational studies in centers across Europe and North America within the framework of the European Network for Translational Research (ENTR) with 25 centers in 8 countries. Over the last five years, the Foundation has successfully expanded its geographical scope providing the context to support transcontinental collaborative research projects. The Global Projects chapter provides the framework to promote research in cirrhosis across the world with the aim to help to build consensus and ensure health equity worldwide.