What is the likelihood of receiving an emergency liver transplant at a hospital?

Likelihood of Receiving an Emergency Liver Transplant

The likelihood of receiving an emergency liver transplant is extremely low—only 29% of patients with acute liver failure (ALF) receive a transplant, while 10% die on the waiting list despite having the highest priority (UNOS Status 1) designation. 1

Critical Reality of Emergency Transplant Access

Acute Liver Failure Outcomes

• In the largest U.S. study, only 29% of ALF patients received a liver graft, while 25% of those listed for transplantation died waiting 1
• Other series report death rates as high as 40% among patients listed for emergency transplant 1
• This occurs despite ALF being the only condition qualifying for the most urgent (UNOS Status 1) listing 1
• Post-transplant survival rates for ALF patients who do receive organs are 80-90%, but accessing a graft remains the primary barrier 1

The Transplant Window Problem

• Patients with fulminant hepatic failure can develop cerebral edema, multiorgan failure, or cardiovascular collapse within days to weeks, making any delay in obtaining a donor organ potentially fatal 1
• The "transplantation window" is often narrow and requires rapid decision-making by a multidisciplinary specialized team 1
• Patients must be referred to a transplant center as quickly as possible for expectant critical care management 1

Factors Affecting Emergency Transplant Likelihood

Clinical Deterioration Timeline

• Waitlist mortality for critically ill patients with cirrhosis ranges from 20-70%, with only a minority making it to transplant 1
• In one single-center study of urgent inpatient liver transplant evaluation: 43% were declined, 33% were waitlisted, 18% died, and only 6% improved—ultimately only 26% underwent transplant 1
• Patients with ACLF grade 3 have 28-day mortality of 76.7% without transplant 2

Regional Variation in Access

• Significant heterogeneity exists among transplant regions—some patients are more likely to drop out of the waitlist than receive a transplant 3
• Region 5 (which transplants at higher MELD scores) experiences 53-64% waitlist dropout 3
• Region 11 (which transplants at lower MELD scores) has 30-44% waitlist dropout 3
• Wait times for patients with MELD 22-27 are projected to double by 2025 3

Prognostic Indicators for Transplant Candidacy

Who Gets Listed for Emergency Transplant

• Urgent hepatic transplantation is indicated in acute liver failure where prognostic indicators suggest a high likelihood of death 1
• Patients predicted to have little chance of spontaneous recovery should undergo transplantation as soon as possible 1
• Improvement or stabilization of organ failures, especially pulmonary and circulatory, may be a prerequisite for listing 1

Contraindications That Reduce Likelihood

• Patients with MELD scores >25 undergoing retransplantation have short-term survival <60% 1
• Patients with MELD >30 have survival rates of only 20-40% with retransplantation 1
• Multiple organ failures (≥3-4 non-hematological failures) at day 3-7 predict in-hospital mortality with 93-100% specificity 1
• Persistence of severe organ dysfunction despite ICU support often leads to delisting 1

Common Pitfalls and Caveats

Timing of Referral

• Contact a transplant center immediately for any patient with severe acute liver failure (PT <50%) 4
• Patients with fulminant hepatic failure should be referred as quickly as possible—delays are often fatal 1
• Early hepatology expert consultation upon ICU admission is critical to determine transplant candidacy 2

Misconceptions About Priority

• While ALF receives Status 1 priority, this does not guarantee organ availability 1
• The organ supply/demand mismatch remains the fundamental constraint 5
• Even with highest priority, 25-40% of listed patients die waiting 1

Selection Bias in Outcomes Data

• Published post-transplant survival rates reflect highly selected patients who survived long enough to receive organs 1
• Many critically ill patients deteriorate before evaluation is complete or organs become available 1
• Intent-to-treat survival (from time of listing) is significantly lower than post-transplant survival 1

Bottom Line for Clinical Practice

The harsh reality is that most patients requiring emergency liver transplantation will not receive one in time. The likelihood depends heavily on:

• Speed of referral to a transplant center 1, 4
• Geographic region and local organ availability 3
• Ability to stabilize organ failures while waiting 1
• Absence of contraindications that develop during the wait 1

Clinicians should initiate transplant evaluation immediately while simultaneously providing maximal supportive care, but must also prepare patients and families for the high probability that an organ will not become available in time. 1