Conclusion: Our study shows that implementation of Share 35 has allowed listed patients with ACLF to get transplanted at a higher rate even after adjusting for MELD. Both univariate and multivariate model showed that patients were more likely to be transplanted in Era 2. Similarly, at 3 months, the CI for LT was 52.6 in Era 1 compared to 57.3 in Era 2 (Gray's k-sample test P=0.0407). At 1 month the CI for LT was 50.7 in Era 1 compared to 54.6 in Era 2. There was a significant difference in the liver transplant CI between the two eras. 584 patients with a mean MELD of 36.8 at listing were identified in Era 1 and 653 patients with a mean MELD of 37.2 in Era 2. Results: A total of 46861 records were reviewed, of which 1237 had ACLF. A proportional hazards model for the sub-distribution of LT was used to estimate the hazard ratio in univariate and multivariate model after adjusting for age, gender and MELD score at listing.
Gray's k-sample test was used to test for equality of CI function between pre-share era and post-share era population.
LT cumulative incidence (CI) was estimated using the cumulative method by Fine and Gray.
Patients’ waitlist status was classified into 3 categories: 1. For the waitlist analysis, a wash-out period of 6 months was used. For the analyses, data were provided for 2 eras 2 years pre-implementation of Share 35 (Era 1, to ) and 2 years post-implementation (Era 2, to ). ACLF was diagnosed using the NACSELD criteria. Methods: Data were obtained and extracted from the United Network for Organ Sharing (UNOS) standard analysis and research file. Our study aimed to compare the waitlist outcomes of patients diagnosed with ACLF, pre, and post-implementation of Share 35. The Share 35 policy was implemented to achieve broader sharing of livers whereby the sickest waitlist candidates (MELD score = 35) are prioritized in a tiered manner regionally before local candidates with MELD scores <35 are offered the livers. Emerging data has shown 1-year post-transplant survival rates of 80- 92% compared to 1-year waitlist survival without LT of 23.5%, supporting LT as a viable therapeutic option. Since liver transplantation (LT) is only available to <10% of candidates each year, ACLF patients are often delisted, and morbidity and mortality rates remain high. Background: Acute on chronic liver failure (ACLF) occurs in nearly 30% of hospitalized cirrhotic patients.
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