LAUSR

To the editor, Concerns of inequity in access to liver transplantation (LT) for patients with acuteonchronic liver failure grade 3 (ACLF3) instigated Artzner et al. to explore variability in listing strategies, LT, and survival in patients with ACLF3 admitted to the intensive care unit (ICU) in 20 transplant centers across Europe.[1] The authors found a correlation between the number of patients with ACLF3 listed and those who received a transplant as well as more favorable survival in patients admitted to “highlisting” centers. The authors conjectured that “the attitude of the center toward wait listing patients with ACLF3 was a key element that defined the variability of transplant activity for these patients across centers.” Consequently, Artzner et al. concluded that patients with ACLF3 face inequity in access to LT across Europe. We would like to highlight several points regarding their pioneering and insightful work. First, the authors state that “a transplant program for patients with ACLF3 may require listing patients who are too ill to be transplanted at the time of listing” with the intention to transplant them when their condition improves. Artzner et al. then propose a “fasttrack” pretransplant assessment (see the Discussion and figure 6 in Artzner et al.[1]). This approach, however, is impractical in many ICUadmitted unlisted patients with ACLF3 because essential pretransplant cardiac workup is frequently unobtainable in candidates who are critically ill. Likewise, accurate social and psychiatric assessments of alcohol addiction and the potential for abstinence may be very limited. Although a rushed addiction evaluation and LT may improve shortterm survival, it is likely to lead to posttransplant relapse, loss of organs, and ultimately reduced utility to the broader LT candidate community. Low waitlist mortality rate is a quality metric for transplant centers. As such, transplant programs may refrain from waitlisting and putting on hold (Status 7, temporarily inactive) candidates who are acutely ill, unstable, and unlisted so that patient mortality is not regarded as waitlist mortality. “High” and “low” listing transplant centers differed significantly in illness severity as a reason for not listing patients with ACLF3 (31% vs. 46%; p = 0.04; table 2 in Artzner et al.[1]). The LT listing practices and criteria for patients with ACLF3 in the 20 transplant centers were not surveyed, and objective data regarding ACLF3 severity, for example, Acute Physiology and Chronic Health Evaluation II, Model for EndStage Liver Disease, or Transplantation for ACLF3 Model scores, were not collected.[2] Yet the authors conjectured that “a lack of consensus defining which patients with ACLF3 should not be transplanted” was at the root cause of listing variability between centers as opposed to a genuine and fundamental difference in ACLF3 acuity. In a previous study, the authors reported a significant variability in the proportion of patients receiving LT for decompensated cirrhosis in Europe.[3] European countries also differ in cirrhosis mortality.[4] Thus ethnic, socioeconomic, and cultural factors impact the natural history of cirrhosis in different localities across Europe. Conceivably, a veritable difference in the clinical presentation and illness severity of ACLF3 underlay the variability in listing patients with ACLF3 between transplant centers. We therefore find that the conclusion of Artzner et al., that the findings of the study unequivocally resulted from inequity in access to LT for patients with ACLF3 across Europe, is questionable. Addressing these points would further strengthen their findings and conclusions.