Pre-operative CT scan helps predict outcome after liver transplantation for acute-on-chronic grade 3 liver failure

Objectives The aim of this study was to identify the prognostic value of pre-operative imaging to predict post-transplantation survival in critically ill cirrhotic patients with severe acute-on-chronic liver failure (ACLF). Methods Patients with grade 3 ACLF who underwent liver transplantation between January 2010 and January 2020 and with available contrast-enhanced abdominal computed tomography (CT) performed less than 3 months before LT were retrospectively included (n = 82). Primary endpoint was 1-year mortality. Imaging parameters (sarcopenia, liver morphology and volumetry, and signs of portal hypertension) were screened and tested to build a prognostic score. Results In the multivariate analysis, three independent CT-derived prognostic factors were found: splenomegaly ( p = 0.021; HR = 5.6 (1.29–24.1)), liver atrophy ( p = 0.05; HR = 2.93 (1.01–10.64)), and vena cava diameter ratio ( p < 0.0001; HR = 12.7 (3.4–92)). A simple prognostic score was proposed, based on the presence of splenomegaly (5 points), liver atrophy (5 points), and vena cava diameter ratio < 0.2 (12 points). A cutoff at 10 points distinguished a high-risk group (score > 10) from a low-risk group (score ≤ 10) with 1-year survival of 27% vs. 67% respectively ( p < 0.001). It was found to be an independent predictive factor in association with the Transplantation for ACLF3 Model (TAM) score. Conclusion Pre-transplantation contrast-enhanced abdominal CT has a significant impact on selection of patients in ACLF3 in order to predict 1-year survival after LT. Key Points • Splenomegaly, liver atrophy, and vena cava diameter ratio are independent CT-derived prognostic factors after transplantation for severe acute-on-chronic liver failure. • A simple CT-based prognostic score is an independent predictive factor, complementary to clinical and biological parameters. • The use of the CT-derived score allows stratification based on 1-year mortality for patients with otherwise uncertain prognosis with clinical and biological parameters alone.