The Impact of Waitlisting After a Weekend on Transplant-Related Outcomes for Patients With Acute Liver Failure in the US

Introduction: Potential delays in patient care during weekends have not been studied in liver transplantation (LT) for acute liver failure (ALF). We evaluated the impact of listing after a weekend on waitlist (WL) and post-LT outcomes in ALF patients. Methods: In a retrospective cohort study of adult ALF patients from February 2002 to May 2023 in the United Network for Organ Sharing (UNOS) database, the primary exposure was listing after a weekend. Multinomial regression and Cox models assessed WL outcomes and post-LT mortality, respectively, adjusting for potential confounders. Inverse probability censoring weighting addressed censoring bias. Results: Among 6600 adults listed for LT, 840 (13%) were listed after a weekend. The median number of days from admission to waitlisting was 2 (IQR1–3). Accounting for potential confounders, patients listed after a weekend had a lower likelihood of spontaneous survival (SS; relative risk ratio 0.74, 95% CI 0.61–0.90, LT as reference). Post-LT mortality at 1 year was higher in patients listed after a weekend (HR 1.25, 95% CI: 1.01–1.54). IPW cohort outcomes corroborated these findings. Conclusions: Among adults with acute liver failure, listing for liver transplantation after a weekend was associated with lower rates of spontaneous survival and higher one-year post-transplant mortality. Identifying system-level factors contributing to delays in transplant evaluation over weekends may help improve the timeliness and efficiency of care.