People with an often-fatal liver condition are being prioritised for liver transplants for the first time thanks to a world-leading NHS change. This life-saving approach is now being considered by other countries across the world.
The British Liver Trust has welcomed the development for patients with acute on chronic liver failure (ACLF), a serious condition which occurs when someone with long-term liver disease develops organ failure. Until now there were very few treatment options for ACLF patients, who are often young adults, and 70% died within 28 days (i). The patients were rarely considered for a liver transplant because of how suddenly they became severely ill and often too quickly to survive a transplant, or they died before a suitable donor could be found.
NHS Blood and Transplant (NHSBT) introduced the changes following work by the NHSBT Liver Advisory Group (ii) and the UK’s seven liver transplant centres. Of the 52 ACLF patients listed for transplant during the pilot phase, 42 received transplants and 77% were alive one year later. By comparison, all 10 of the people who did not receive transplants sadly died within 13 days (iii) (iv). The patient group was aged between 39 to 52.
This is the first time critically ill ACLF patients have been prioritised in a planned national transplant programme. This is also the first time liver transplants have been shown to be a practical and highly effective treatment for selected ACLF patients when no other treatment option existed.
Pamela Healy, Chief Executive of the British Liver Trust said: “This type of liver disease is devastating and can often affect relatively young people in their thirties or forties. We often hear from distressed families whose loved ones have experienced rapid decline and were faced with a heart-breaking lack of options, leading to tragic outcomes. This new transplant program offers genuine hope for those suffering from this condition.”
Professor William Bernal (pictured) of the Liver Intensive Therapy Unit at Kings College Hospital developed the service and worked with other clinicians to deliver the pilot on behalf of the NHSBT Liver Advisory Group. He said: “As a doctor working in a liver intensive care unit I was used to seeing the devastating impact of this condition. It was truly heart-breaking to see young people come into the unit with multiple organ failure and as a doctor have very few options to keep them alive.
“These patients now have access to a lifesaving therapy for the first time. I feel a sense of pride at seeing the results. There is an urgent clinical need for interventions to improve survival for people with this disease, which causes many of the two million deaths from chronic liver disease world-wide each year.”
British Liver Trust trustee Professor Douglas Thorburn, the Divisional Clinical Director for Liver and Digestive Health at the Royal Free, and chair of the NHSBT Liver Advisory Group when the change was introduced, said: “The UK liver transplant community collaborated effectively to develop a way to prioritise these patients. This was transformative because there is no other effective treatment available.”
(ii) The major role of the organ advisory groups is to advise NHSBT is to help promote all aspects of organ transplantation and ensure equity of access and best outcomes for all patients. Membership includes NHSBT staff, clinical representatives from the transplant centres, and patient lay members. https://www.odt.nhs.uk/transplantation/liver/liver-advisory-group/
(iii) The eligibility criteria specified that all cases should have cirrhosis without other comorbidity that would preclude standard liver transplant, be requiring critical care support and have ACLF defined using European Foundation for the Study of Chronic Liver Failure (EF-CLIF) criteria with expected 1-month mortality exceeding 50%; most were expected to be ACLF Grade 3 1. All cases had to have evidence of severe liver failure manifested by clinically significant jaundice and coagulopathy, and thus an illness that would be corrected by LT. All cases must be below 60 years of age, a consistent threshold for poor post-LT survival in retrospective series, and patients who previously underwent LT were not eligible for consideration. 28-day 90-day and 1-year survival after registration was 93%, 86% and 77 % respectively.
(iv) The Lancet paper says transplantation for ACLF was more resource intensive – for example hospitals stays were about double that of normal, elective liver transplants – and that while survival rates are higher than expected they are lower than for elective transplants. However, it says a scoring system could establish which ACLF patients which have the best chance of survival. It also notes ACLF liver transplant is new and outcomes could be expected to improve as the service developments, as it did for Acute Liver Failure transplantation in the 1980s and 1990s.
