Résumé
Background and Aims: Liver transplantation (LT) remains the definitive treatment for patients with end-stage chronic liver disease (CLD). However, those transplanted while in intensive care unit (ICU) represent a high-risk population. Large-scale data on long-term prognosis in this group are limited. We aimed to assess long-term outcomes in CLD patients undergoing LT from the ICU and to compare outcomes over time.Methods: This retrospective cohort study used the French national transplant registry (CRISTAL). Adults with CLD who underwent LT from the ICU between 2008 and 2018 were included. Organ failures were defined according to EASL CLIF-OF criteria. Five-year survival and associated risk factors were analyzed and compared across four time periods (2008–2010, 2011–2013, 2014–2016, 2017–2018).Results: Among 13,372 LTs performed in France during the study period, 9,686 were for CLD, of whom 1,287 (13.2%) were in the ICU at the time of LT. Alcohol-related liver disease (50%) and viral hepatitis (16.1%) were the leading etiologies. Five-year survival was significantly lower in CLD-ICU patients compared to non-ICU patients (69.2% vs. 79.1%, p<0.0001). Among 1-year survivors, 5-year survival exceeded 83% and was not different to that of CLD patients transplanted outside ICU. Survival by era showed no significant improvement (p=0.28). Age (HR 1.03, p<0.0001), mechanical ventilation (HR 1.57, p=0.0001) and French Donor Risk Score (HR 1.05, 95%CI [1.02-1.09], p<0.001) were independent predictors of mortality.ConclusionPatients transplanted from the ICU have significantly lower long-term survival, primarily due to elevated early post-transplant mortality, with no observed improvement over time. Careful candidate evaluation and donor selection remain critical to improving outcomes in this high-risk population.Impact and Implications: This large national cohort study provides a comprehensive evaluation of long-term outcomes in critically ill cirrhotic patients undergoing liver transplantation while in the ICU. Despite advances in transplant care over the past decade, we observed a persistent survival gap in this high-risk population, primarily driven by increased mortality within the first year after transplantation. Age, the need for mechanical ventilation, and donor-related factors were independently associated with this excess risk. We also found no significant improvement in outcomes over time. These results underscore the continued need for refined candidate selection and donor allocation strategies, taking into account age, pre-transplant clinical stability, and graft quality to optimize post-transplant survival.Trial Registration: ClinicalTrials.gov number NCT06636409