*Purpose: Spontaneous survival rates in acute liver failure (ALF) are vastly improved by liver transplantation (LT). However, the value of induction agents beyond steroids continues to be debated. To understand the potential benefit of different induction regimens in the ALF population, we compared one-year survival of recipients undergoing LT in the United States for ALF.

*Methods: Utilizing the Scientific Registry of Transplant Recipients, we assessed the impact of induction immunosuppression (IS) in a cohort of 3754 first-time liver transplant recipients with a diagnosis of ALF from 2002 – 2018. Induction IS therapy was grouped into steroid-only induction, use of anti-thymocyte globulin (ATG) or Interleukin-2 receptor antibody (IL-2Ra). Other regimens were excluded from analysis. Survival analysis was estimated via Cox proportional hazard models and expressed as hazard ratios (HR).

*Results: In LT for ALF, use of induction agents beyond steroids is increasingly frequent over the last two decades. Use of ATG is associated with worse one-year survival, even after adjusting for donor and recipient factors, with HR of 1.26 (1.02 – 1.56, p 0.03). An increase in cold ischemic time, recipient and donor age, black ethnicity, and prior surgery were all associated with reduced survival whereas maintenance immunosuppression with calcineurin inhibitors (CNI) was associated with improved one-year survival.

*Conclusions: While adjunct induction therapy has become more common, our analysis shows that compared to a steroid- only induction regimen, the addition of ATG is associated with worse one-year survival after liver transplant ALF. CNI maintenance was highly protective, suggesting an immunosuppression strategy focusing on corticosteroids-only induction followed by CNI maintenance may offer the best one-year survival rates.

« Back to 2020 American Transplant Congress