Highlights
- •UNOS studies on ACLF are informing global transplant allocation policies, but the validity of these data is unknown.
- •We found that ACLF identified by UNOS is only weakly concordant with chart review.
- •Classification of acute decompensation and brain/respiratory failures are common sources of discordance.
- •These data highlight the importance of prospective studies regarding ACLF in LT and should encourage UNOS reform.
Background & Aims
Studies regarding acute-on-chronic liver failure (ACLF) among liver transplant (LT)
candidates from the United Network for Organ Sharing (UNOS) database are being used
to inform LT policy changes worldwide. We assessed the validity of identifying ACLF
in UNOS.
Methods
We performed stratified random sampling among 3 US LT centers between 2013-2019 to
obtain a representative patient sample across ACLF grades. We compared the concordance
of ACLF classification by UNOS vs. blinded manual chart review, according to EASL-CLIF.
Results
Among 481 sampled LT registrants, 250 (52%) had no ACLF, 75 (16%) had ACLF grade 1,
79 (16%) had ACLF grade 2, and 77 (16%) had ACLF grade 3 per UNOS categorization.
Concordance of ACLF grade by UNOS vs. chart review was: 72%, 64%, 56%, and 64% for no ACLF, grade 1, grade 2, and grade
3, respectively, with an overall Cohen’s kappa coefficient of 0.48 (95% CI 0.42–0.54).
Absence of acute decompensation was the most common reason for overestimation, and
discordant brain and respiratory failure categorization were the most common reasons
for underestimation of ACLF by UNOS.
Conclusions
In this retrospective multi-center study, ACLF categorization by UNOS showed weak
agreement with manual chart review. These findings are informative for ongoing allocation
policy discussions, highlight the importance of prospective studies regarding ACLF
in LT, and should encourage UNOS reform.
Lay summary
Acute-on-chronic-liver-failure (ACLF) is a specific and common form of liver failure
associated with high death rates. Studies have been published using the United States
transplant registry (UNOS) to identify and describe outcomes of transplant candidates
and recipients with ACLF, and these data are driving policy changes for transplant
allocation around the world, but nobody has shown whether these data are reliable.
We found that UNOS was not categorizing ACLF in concordance or accurately when compared
to chart review, which shows the need for UNOS reform and non-UNOS studies to appropriately
inform policies regarding the transplantation of patients with ACLF.
Graphical abstract
Graphical Abstract
Keywords
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Article info
Publication history
Published online: January 21, 2022
Accepted:
December 28,
2021
Received in revised form:
December 7,
2021
Received:
November 1,
2021
Footnotes
Author names in bold designate shared co-first authorship
Identification
Copyright
© 2022 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.
