Transplant center experience influences spontaneous survival and waitlist mortality in acute liver failure: an analysis of the UNOS database.

Transplant centers coordinate complex care in acute liver failure (ALF), for which liver transplantation (LT) can be lifesaving. We studied associations between waitlist outcomes and center (i) ALF waitlist volume (low: <20; medium: 20-39; high: 40+ listings) and (ii) total LT volume (<600; 600-1199; 1200+ LTs) in a retrospective cohort of 3,248 adults with ALF listed for LT at 92 centers nationally from 2002-2019. Predicted outcome probabilities (LT, died/too sick, spontaneous survival [SS]) were obtained with multinomial regression, and observed-to-expected (O/E) ratios were calculated. Median center outcome rates were: 72.6% LT, 18.2% died/too sick, and 6.1% SS. SS was significantly higher with greater center ALF volume (median 0% for low-, 5.9% for medium- and 8.6% for high-volume centers; p=0.039), while waitlist mortality was highest at low-volume centers (median 21.4%, IQR: 16.1-26.7%; p=0.042). Significant heterogeneity in center performance was observed for waitlist mortality (O/E ratio range: 0-4.1) and particularly for SS (0-6.4), which persisted despite accounting for recipient case-mix. This novel study demonstrates that increased center experience is associated with greater SS and reduced waitlist mortality for ALF. More focused management pathways are needed to improve ALF outcomes at less experienced centers and to identify opportunities for improvement at large.