CHANCE Study Links Liver Transplantation With Higher 1-Year Survival in Severe ACLF

Patients with grade 2 or grade 3 acute-on-chronic liver failure (ACLF) who underwent liver transplantation (LT) had markedly lower 1-year mortality than patients who were declined for transplant, according to the prospective CHANCE study published online in the Journal of Hepatology.

The investigators noted that the effect of LT on mortality in patients with advanced cirrhosis and 2 organ failures (ACLF-2) or 3 or more organ failures (ACLF-3) has been unclear. The investigator-initiated, multicenter, observational cohort study (NCT04613921), sponsored by the European Foundation for the Study of Chronic Liver Failure, enrolled adults with decompensated cirrhosis at 63 transplant centers in Asia, Europe, Latin America, and North America from July 2021 to October 2023. Patients were followed for 1 year.

Among 144 patients with ACLF-2 or ACLF-3 who were declined for LT, 73% and 88%, respectively, died within 1 year. Among 612 transplanted patients, the 1-year case-fatality rate without re-transplantation was 20.7% with ACLF-3 at LT, 10.5% with ACLF-2, 10% with ACLF-1, and 9% without ACLF. The rate reached 41.7% in patients with 5 or more organ failures at LT.

In multivariable analyses, ACLF-3 at LT was associated with higher post-LT mortality vs no ACLF (subdistribution hazard ratio, 3.36; 95% CI, 1.74-6.49), as was undergoing LT in Asia vs Europe or North America. The investigators reported that 89% of LTs in Asia used living donors. Recipients with ACLF-3 had longer intensive care stays but similar ward stays, readmission rates, and need for long-term renal replacement therapy.

The authors cited several limitations, including LT selection criteria left to local teams, possible inclusion bias because listed patients appeared less severe than those declined, a post hoc sample-size recalculation, and only 24 patients with 5 or more organ failures. They concluded that the high risk of death after LT in patients with 5 or 6 organ failures cautions against routine LT in this population.

Source: Gustot T, Bernal W, Fernández J, et al. Survival outcomes after liver transplantation in acute-on-chronic liver failure: a prospective study. J Hepatol. Published online October 1, 2026. doi:10.1016/j.jhep.2026.09.015