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Müller M, Grasshoff C. [The Role of the Anaesthesiologist in Liver Transplantation - Preoperative Evaluation]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:283-295. [PMID: 38759684 DOI: 10.1055/a-2152-7350] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/19/2024]
Abstract
Preoperative evaluation prior to listing for orthotopic liver transplantation (LT) requires a careful multidisciplinary approach with specialized teams including surgeons, hepatologists and anesthesiologists in order to improve short- and long-term clinical outcomes. Due to inadequate supply of donor organs and changing demographics, patients listed for LT have become older, sicker and share more comorbidities. As cardiovascular events are the leading cause for early mortality precise evaluation of risk factors is mandatory. This review focuses on the detection and management of coronary artery disease, cirrhotic cardiomyopathy, portopulmonary hypertension and hepatopulmonary syndrome in patients awaiting LT. Further insights are being given into scoring systems, patients with Acute-on-chronic-liver-failure (ACLF), frailty, NASH cirrhosis and into psychologic evaluation of patients with substance abuse.
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Yun SO, Kim J, Rhu J, Choi GS, Joh JW. Benefit of living donor liver transplantation in graft survival for extremely high model for end-stage liver disease score ≥35. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2023; 30:1293-1303. [PMID: 37799067 DOI: 10.1002/jhbp.1376] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/21/2023] [Revised: 07/23/2023] [Accepted: 07/27/2023] [Indexed: 10/07/2023]
Abstract
BACKGROUND AND AIMS Living liver donation with high model for end-stage liver disease (MELD) score was discouraged despite organ shortage. This study aimed to compare graft survival between living donor liver transplantation (LDLT) and deceased donor liver transplantation (DDLT) recipients with extremely high-MELD (score of ≥35). METHODS Between 2008 and 2018, 359 patients who underwent liver transplantation with a MELD score ≥35 were enrolled. We compared graft survival between LDLT and DDLT after propensity score matching (PSM) and performed subgroup analysis according to donor type. RESULTS After PSM, there was no statistical difference in graft survival between the LDLT and DDLT groups (p = .466). Old age, acute on chronic liver failure, re-transplantation, preoperative intensive care unit stay and red blood cell (RBC) transfusion during the operation were risk factors for graft failure (p = .046, .005, .032, .015 and .001, respectively). Biliary complications were more common in the LDLT group (p = .021), while viral infection, postoperative uncontrolled ascites, and postoperative hemodialysis were more common in the DDLT group (p = .002, .018, and .027, respectively). In the LDLT group, acute chronic liver failure, intraoperative RBC transfusion, and early postoperative complications were risk factors for graft failure (p = .007, <.001, and .001, respectively). CONCLUSION Our study showed that LDLT is not inferior to DDLT in graft survival if appropriate risk evaluation is performed in cases of extremely high-MELD scores. This result will help overcome organ shortages in high-MELD liver transplantation.
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Affiliation(s)
- Sang Oh Yun
- Department of Surgery, Kyung Hee University Hospital, Kyung Hee University School of Medicine, Dongdaemun-gu, Seoul, Korea
| | - Jongman Kim
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Gangnam-gu, Korea
| | - Jinsoo Rhu
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Gangnam-gu, Korea
| | - Gyu-Seong Choi
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Gangnam-gu, Korea
| | - Jae-Won Joh
- Department of Surgery, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Gangnam-gu, Korea
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Kwon HM, Kim JH, Kim JY, Hwang GS. Five-year all-cause mortality in critically ill liver transplant patients with coronary artery disease: analysis of acute-on chronic liver failure. Anesth Pain Med (Seoul) 2022; 17:412-419. [DOI: 10.17085/apm.22168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2022] [Accepted: 08/01/2022] [Indexed: 11/07/2022] Open
Abstract
Background: Patients with acute-on-chronic liver failure (ACLF) are critically ill and have high waiting-list mortality. Although studies demonstrated that appropriately treated coronary artery disease (CAD) should not be regarded as a contraindication to liver transplant (LT), data regarding long-term outcomes in critically ill liver LT recipients are lacking. The aim of this study was to compare the rates of all-cause death at 5 years following LT in patients with ACLF with or without CAD.Methods: Between 2010 and 2020, we evaluated 921 consecutive LT patients (MELD score, 32 ± 9) and ACLF classified by CLIF-C ACLF score. Up to 5-year all-cause death according to the CAD status was examined. CAD was defined as a preoperative history of coronary artery bypass graft or a percutaneous intervention and old myocardial infarction. Kaplan-Meier survival analysis was used.Results: Up to 5 years, 212 (23.0%) of all ACLF patients (n = 921) in whom 17 (29.3%) of 58 CAD patients died. In patients with CAD (6.3%, 58/921), the Kaplan-Meier cumulative mortality rate at 5 years was numerically higher but was not statistically significant when compared with those without CAD (32.9% vs. 23.5%, log-rank, P = 0.25). In subgr oup analysis, there were comparable risks of cumulative mortalities at 5 years across the stratification of ACLF grade 1, 2, and 3 (log-rank P = 0.062, P = 0.72, and P = 0.999, respectively).Conclusions: All-cause mortality is high in patients with ACLF after LT but is not related to the presence of revascularized or treated CAD, across the stratification of ACLF grades.
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Sarno G, Schiavo L, Calabrese P, Álvarez Córdova L, Frias-Toral E, Cucalón G, Garcia-Velasquez E, Fuchs-Tarlovsky V, Pilone V. The Impact of Bariatric-Surgery-Induced Weight Loss on Patients Undergoing Liver Transplant: A Focus on Metabolism, Pathophysiological Changes, and Outcome in Obese Patients Suffering NAFLD-Related Cirrhosis. J Clin Med 2022; 11:jcm11185293. [PMID: 36142939 PMCID: PMC9503676 DOI: 10.3390/jcm11185293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 08/28/2022] [Accepted: 09/05/2022] [Indexed: 11/30/2022] Open
Abstract
Because of their condition, patients with morbid obesity develop several histopathological changes in the liver, such as non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH), cirrhosis, and end-stage liver disease (ESLD). Hence, a liver transplant (LT) becomes an opportune solution for them. Due to many challenges during the perioperative and postoperative periods, these patients are recommended to lose weight before the surgery. There are many proposals to achieve this goal, such as intragastric balloons and many different bariatric surgery (BS) procedures in combination with a preparation diet (very-low-calorie diet, ketogenic diet, etc.). All the interventions focus on losing weight and keeping the continuity and functionality of the digestive tract to avoid postoperative complications. Thus, this review analyzes recent publications regarding the metabolic and pathophysiological impacts of BS in LT patients suffering from NAFLD-related cirrhosis, the effect of weight loss on postoperative complications, and exposes the cost-effectiveness of performing BS before, after, and at liver transplantation. Finally, the authors recommend BS before the LT since there are many positive effects and better outcomes for patients who lose weight before the procedure. Nevertheless, further multicentric studies are needed to determine the generalizability of these recommendations due to their impact on public health.
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Affiliation(s)
- Gerardo Sarno
- San Giovanni di Dio e Ruggi D’Aragona University Hospital, Scuola Medica Salernitana, 84131 Salerno, Italy
| | - Luigi Schiavo
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, P.O. Gaetano Fucito Mercato San Severino, 84085 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Baronissi, Italy
- Correspondence: ; Tel.: +39-089-965062
| | - Pietro Calabrese
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, P.O. Gaetano Fucito Mercato San Severino, 84085 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Baronissi, Italy
| | - Ludwig Álvarez Córdova
- Carrera de Nutrición y Dietética, Facultad de Ciencias Médicas, Universidad Católica De Santiago de Guayaquil, Av. Pdte. Carlos Julio Arosemena Tola, Guayaquil 090615, Ecuador
| | - Evelyn Frias-Toral
- School of Medicine, Universidad Católica Santiago de Guayaquil, Av. Pdte. Carlos Julio Arosemena Tola, Guayaquil 090615, Ecuador
- Universidad de Especialidades Espìritu Santo, Samborondòn 0901952, Ecuador
| | - Gabriela Cucalón
- Lifescience Faculty, ESPOL Polytechnic University, Escuela Superior Politécnica del Litoral (ESPOL), Campus Gustavo Galindo Km. 30.5 Vía Perimetral, Guayaquil 090615, Ecuador
| | | | | | - Vincenzo Pilone
- Center of Excellence of Bariatric Surgery of the Italian Society of Obesity Surgery and Metabolic Disease (SICOB), Unit of General and Emergency Surgery, University Hospital San Giovanni di Dio e Ruggi d’Aragona, P.O. Gaetano Fucito Mercato San Severino, 84085 Salerno, Italy
- Department of Medicine, Surgery and Dentistry, Scuola Medica Salernitana, University of Salerno, 84081 Baronissi, Italy
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5
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Predictive factors of inhospital mortality for ICU patients with acute-on-chronic liver failure undergoing liver transplantation. Eur J Gastroenterol Hepatol 2022; 34:967-974. [PMID: 35913780 DOI: 10.1097/meg.0000000000002413] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/10/2022]
Abstract
INTRODUCTION Liver transplantation (LT) is the only effective treatment for acute-on-chronic liver failure (ACLF), but it is limited by organ availability. This study aims to identify predictive factors of mortality for LT candidates based on parameters measured at the admission into the ICU. METHODS Sixty-four patients diagnosed with ACLF, admitted consecutively into ICU between 2015 and 2019, were retrospectively enrolled in the study. Data were assessed using univariate and multivariate regression analyses to identify risk factors for inhospital mortality and 1-year mortality. RESULTS A total of 67% of patients were diagnosed with ACLF grade 3, and 25 and 8% with grades 2 and 1. Thirty percent received LT with a 1-year mortality rate of 16%, whereas for nontransplanted patients it reached 90%. Clinical features were compared according to transplant eligibility. In the univariate analysis model, lung failure (HR, 3.01; 95% CI, 1.48-6.09; P = 0.002), high lactate levels (HR, 1.03; 95% CI, 1.02-1.04; P < 0.001) and CLIF-ACLF score (HR, 1.04; 95% CI, 1.01-1.09; P = 0.026) were independently correlated to increased inhospital mortality. LT reduced mortality risk (HR, 0.16; 95% CI, 0.04-0.72; P = 0.016). CONCLUSION Lung failure, CLIF-ACLF score and blood lactate levels at admission were the only statistically significant independent predictors of inhospital mortality, more accurate in determining transplant success than ACLF grade.
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Artzner T, Bernal W, Belli LS, Conti S, Cortesi PA, Sacleux SC, Pageaux GP, Radenne S, Trebicka J, Fernandez J, Perricone G, Piano S, Nadalin S, Morelli MC, Martini S, Polak WG, Zieniewicz K, Toso C, Berenguer M, Iegri C, Invernizzi F, Volpes R, Karam V, Adam R, Faitot F, Rabinowich L, Saliba F, Meunier L, Lesurtel M, Uschner FE, Michard B, Coilly A, Meszaros M, Poinsot D, Besch C, Schnitzbauer A, De Carlis LG, Fumagalli R, Angeli P, Arroyo V, Fondevila C, Duvoux C, Jalan R. Location and allocation: Inequity of access to liver transplantation for patients with severe acute-on-chronic liver failure in Europe. Liver Transpl 2022; 28:1429-1440. [PMID: 35544360 DOI: 10.1002/lt.26499] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2022] [Accepted: 03/29/2022] [Indexed: 01/13/2023]
Abstract
There is growing evidence that liver transplantation (LT) is the most effective treatment for acute-on-chronic liver failure grade-3 (ACLF-3). This study examines whether and how this evidence translates into practice by analyzing the variability in intensive care unit (ICU) admissions, listing strategies, and LT activity for patients with ACLF-3 across transplantation centers in Europe. Consecutive patients who were admitted to the ICU with ACLF-3, whether or not they were listed and/or transplanted with ACLF-3, between 2018 and 2019 were included across 20 transplantation centers. A total of 351 patients with ACLF-3 were included: 33 had been listed prior to developing ACLF-3 and 318 had not been listed at the time of admission to the ICU. There was no correlation between the number of unlisted patients with ACLF-3 admitted to the ICU and the number listed or transplanted while in ACLF-3 across centers. By contrast, there was a correlation between the number of patients listed and the number transplanted while in ACLF-3. About 21% of patients who were listed while in ACLF-3 died on the waiting list or were delisted. The percentage of LT for patients with ACLF-3 varied from 0% to 29% for those transplanted with decompensated cirrhosis across centers (average = 8%), with an I2 index of 68% (95% confidence interval, 49%-80%), showing substantial heterogeneity among centers. The 1-year survival for all patients with ACLF-3 was significantly higher in centers that listed and transplanted more patients with ACLF-3 (>10 patients) than in centers that listed and transplanted fewer: 36% versus 20%, respectively (p = 0.012). Patients with ACLF-3 face inequity of access to LT across Europe. Waitlisting strategies for patients with ACLF-3 influence their access to LT and, ultimately, their survival.
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Affiliation(s)
- Thierry Artzner
- Service de Réanimation Médicale, Hôpital de Hautepierre, Strasbourg, France
| | - William Bernal
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Luca S Belli
- Hepatology and Gastroenterology Unit, ASST GOM Niguarda, Milan, Italy
| | - Sara Conti
- Value-Based Healthcare Unit, IRCCS Multi Medica, Sesto San Giovanni, Italy.,Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Paolo A Cortesi
- Value-Based Healthcare Unit, IRCCS Multi Medica, Sesto San Giovanni, Italy.,Research Centre on Public Health (CESP), University of Milan-Bicocca, Monza, Italy
| | - Sophie-Caroline Sacleux
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Unité INSERM 1193, Université Paris-Saclay, Villejuif, France
| | - George-Philippe Pageaux
- Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, University of Montpellier, France
| | - Sylvie Radenne
- Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, HCL Hôpital de la Croix-Rousse, Lyon, France
| | - Jonel Trebicka
- Translational Hepatology, Department of Internal Medicine, Goethe University, Frankfurt, Germany.,European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain
| | - Javier Fernandez
- Liver ICU, Liver Unit, Institute of Digestive and Metabolic Diseases, Hospital Clinic, University of Barcelona, IDIBAPS and CIBERehd, Barcelona, Spain.,School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | | | - Salvatore Piano
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Silvio Nadalin
- Department of General, Visceral and Transplant Surgery, University Hospital Tübingen, Germany
| | - Maria C Morelli
- IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Silvia Martini
- Gastro-hepatology Unit, Azienda Ospedaliera Universitaria, Città della Salute e della Scienza di Torino, University of Torino, Torino, Italy
| | - Wojciech G Polak
- University Medical Center Rotterdam Department of Surgery, Division of HPB and Transplant Surgery, Erasmus MC, Transplant Institute, Rotterdam, the Netherlands
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Christian Toso
- Division of Abdominal Surgery, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Marina Berenguer
- Hepatology and Liver Transplantation Unit, CIBEREHD, Hospital General Universitario Gregorio Marañón, Universidad Complutense, Madrid, Spain.,Faculty of Medicine, La Fe University Hospital, Valencia, Spain
| | - Claudia Iegri
- Gastroenterology Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Federica Invernizzi
- Division of Gastroenterology and Hepatology, CRC "A. M. and A. Migliavacca" Center for Liver Disease, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Riccardo Volpes
- Hepatology and Gastroenterology Unit, ISMETT-IRCCS, Palermo, Italy
| | - Vincent Karam
- European Liver Transplant Registry, Centre Hépato-Biliaire Hôpital Universitaire Paul-Brousse, Villejuif, France
| | - René Adam
- European Liver Transplant Registry, Centre Hépato-Biliaire Hôpital Universitaire Paul-Brousse, Villejuif, France
| | - François Faitot
- Service de Chirurgie Hépato-Biliaire et Transplantation Hépatique, Hôpital de Hautepierre, Strasbourg, France
| | - Liane Rabinowich
- Liver Intensive Therapy Unit, Institute of Liver Studies, Kings College Hospital, London, UK
| | - Faouzi Saliba
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Unité INSERM 1193, Université Paris-Saclay, Villejuif, France
| | - Lucy Meunier
- Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, University of Montpellier, France
| | - Mickael Lesurtel
- Department of Digestive Surgery and Liver Transplantation, Croix Rousse Hospital, Hospices Civils de Lyon, University of Lyon I, Lyon, France
| | - Frank E Uschner
- Translational Hepatology, Department of Internal Medicine, Goethe University, Frankfurt, Germany
| | - Baptiste Michard
- Service de Chirurgie Hépato-Biliaire et Transplantation Hépatique, Hôpital de Hautepierre, Strasbourg, France
| | - Audrey Coilly
- AP-HP Hôpital Paul-Brousse, Centre Hépato-Biliaire, Unité INSERM 1193, Université Paris-Saclay, Villejuif, France
| | - Magdalena Meszaros
- Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, Saint Eloi Hospital, University of Montpellier, France
| | - Domitille Poinsot
- Department of Hepatogastroenterology, Hepatology and Liver Transplantation Unit, HCL Hôpital de la Croix-Rousse, Lyon, France
| | - Camille Besch
- Service de Chirurgie Hépato-Biliaire et Transplantation Hépatique, Hôpital de Hautepierre, Strasbourg, France
| | - Andreas Schnitzbauer
- Translational Hepatology, Department of Internal Medicine, Goethe University, Frankfurt, Germany
| | - Luciano G De Carlis
- School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy.,General Surgery and Transplantation Unit, ASST GOM Niguarda, Milan, Italy
| | - Roberto Fumagalli
- Department of Anesthesia, Critical Care, ASST GOM Niguarda, School of Medicine and Surgery, University of Milano-Bicocca, Milan, Italy
| | - Paolo Angeli
- Unit of Internal Medicine and Hepatology (UIMH), Department of Medicine, University of Padova, Padova, Italy
| | - Vincente Arroyo
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain
| | | | | | - Rajiv Jalan
- European Foundation for the Study of Chronic Liver Failure (EF Clif), Barcelona, Spain.,Liver Failure Group, Institute for Liver and Digestive Health, UCL Medical School, London, UK
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Artzner T, Legeai C, Antoine C, Jasseron C, Michard B, Faitot F, Schneider F, Bachellier P. Liver transplantation for critically ill cirrhotic patients: Results from the French transplant registry. Clin Res Hepatol Gastroenterol 2022; 46:101817. [PMID: 34607069 DOI: 10.1016/j.clinre.2021.101817] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/24/2021] [Revised: 09/14/2021] [Accepted: 09/18/2021] [Indexed: 02/04/2023]
Abstract
This study describes the population of cirrhotic patients who were transplanted from the ICU in France, identifying pre-transplant risk factors of post-transplant mortality and describing geographic variations in ICU transplant activity. Cirrhotic patients transplanted between 2008 and 2018 were included through the national transplant registry. The demographic, clinical and biological characteristics of the patients transplanted from the ICU were compared to cirrhotic patients who were transplanted from home or from the hospital. Risk factors of post-transplant one-year mortality were identified in uni- and multivariable analysis within the population transplanted from the ICU. Funnel plots were used to illustrate center-specific differences in ICU transplant activity. 1,047 cirrhotic patients were transplanted from the ICU during the study period. While the national rate of transplants performed from the ICU was 14.3% the absolute number and the rate of cirrhotic patients transplanted from the ICU varied significantly from one center to another, ranging from 6.6% to 22.8% (p < 0.05). Three recipient-associated independent risk factors one-year post-LT mortality were identified in the population transplanted from the ICU: age > 50 years (HR 1.65, 95%CI 1.16-2.36), p = 0.005), diabetes (HR 1.46, 95%CI 1.07-1.98, p = 0.02) and intubation (HR2.12, 95%CI 1.62-2.78), p < 0.001). Donor age was also independently associated with mortality (HR 1.01, 95%CI 1.01-1.02, p < 0.001). Funnel plots showed significant differences in the proportion of patients transplanted from the ICU and the distribution of risk factors across French transplant centers, especially the inclination to transplant intubated patients. This study underlines the increased post-transplant mortality among cirrhotic patients transplanted from the ICU. It identifies four clinically pertinent independent risk factors associated with post-transplant mortality in this specific sub-group of transplant candidates. Finally, it illustrates how diverse the landscape of liver transplantation for critically ill cirrhotic patients is across a single country, despite a unified allocation algorithm.
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8
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Michard B, Artzner T, Deridder M, Besch C, Addeo P, Castelain V, Guillot M, Harlay ML, Herbrecht JE, Janssen Langenstein R, Schenck M, Bachellier P, Schneider F, Faitot F. Pretransplant Intensive Care Unit Management and Selection of Grade 3 Acute-on-Chronic Liver Failure Transplant Candidates. Liver Transpl 2022; 28:17-26. [PMID: 34431204 DOI: 10.1002/lt.26280] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2021] [Revised: 07/20/2021] [Accepted: 08/06/2021] [Indexed: 12/15/2022]
Abstract
The aim of this study is to report on the liver transplantation (LT) activity and posttransplant outcome, over time, of patients with grade 3 acute-on-chronic liver failure (ACLF-3) in a single transplant center performing a large number of LTs for patients with ACLF-3. It aims at showing how pre-LT intensive care unit (ICU) management impacts post-LT outcomes, in particular through monitoring the transplantation for ACLF-3 model (TAM) score. A total of 100 patients who had ACLF-3 at the time of LT between 2007 and 2019 were included retrospectively. The cohort was divided in 2 periods, with 50 patients in each period. There was an increase in the number of patients with ACLF-3 who received an LT during the course of the study period and significantly higher 1-year post-LT survival rates in the second period compared with the first period (86% versus 66%, respectively; P = 0.02). Interestingly, patients during both periods had similar severity profiles and scores apart from a significantly lower number of patients with TAM scores >2 at the time of LT in the second period compared with the first period (1 [2%] versus 11 [22%], respectively; P ≤ 0.01). In addition, patients whose clinical condition improved in the ICU (with a TAM score downstaged between admission and LT) had significantly higher post-LT survival rates than those whose TAM score stayed the same or increased: 88% versus 70%, respectively (P = 0.04). This study shows a learning curve in LT for patients with ACLF-3, with optimized ICU management and patient selection leading to increased numbers of LTs for patients with ACLF-3 and improved post-LT outcomes. It also delineates how the TAM score can be used to identify the optimal transplantability window for patients with ACLF-3.
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Affiliation(s)
- Baptiste Michard
- Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Thierry Artzner
- Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Mathilde Deridder
- Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Camille Besch
- Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Pietro Addeo
- Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Vincent Castelain
- Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Max Guillot
- Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Marie-Line Harlay
- Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | | | | | - Maleka Schenck
- Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Philippe Bachellier
- Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Francis Schneider
- Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - François Faitot
- Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
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9
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Choudhury A, Vijayaraghavan R, Maiwall R, Kumar M, Duan Z, Yu C, Hamid SS, Jafri W, Butt AS, Devarbhavi H, Ning Q, Ma K, Tan SS, Shukla A, Dhiman R, Duseja A, Taneja S, Eapen CE, Goel A, Treeprasertsuk S, Al-Mahtab M, Ghazinyan H, Kim DJ, Sahu MK, Lee GH, Lesmana LA, Lesmana RC, Shah S, Abbas Z, Sollano JD, Rao PN, Kulkarni A, Shiha G, Shrestha A, Dokmeci AK, Yuen MF, Payawal DA, Kalista KF, Prasad VGM, Lau GK, Karim F, Jain P, Kumar G, Arora V, Pamecha V, Sinha P, Sarin SK. 'First week' is the crucial period for deciding living donor liver transplantation in patients with acute-on-chronic liver failure. Hepatol Int 2021; 15:1376-1388. [PMID: 34608586 DOI: 10.1007/s12072-021-10206-6] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2020] [Accepted: 04/30/2021] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIMS Acute-on-chronic liver failure (ACLF) is a rapidly progressive illness with high short-term mortality. Timely liver transplant (LT) may improve survival. We evaluated various indices for assessment of the severity of liver failure and their application for eligibility and timing of living donor LT (LDLT). METHODS Altogether 1021 patients were analyzed for the severity and organ failure at admission to determine transplant eligibility and 28 day survival with or without transplant. RESULTS The ACLF cohort [mean age 44 ± 12.2 years, males 81%) was of sick patients; 55% willing for LT at admission, though 63% of them were ineligible due to sepsis or organ failure. On day 4, recovery in sepsis and/or organ failure led to an improvement in transplant eligibility from 37% at baseline to 63.7%. Delay in LT up to 7 days led to a higher incidence of multiorgan failure (p < 0.01) contributing to 23% of the first week and 55% of all-cause 28-day mortality. In a matched cohort analysis, the actuarial survival with LT (n = 41) and conditional survival in the absence of transplant (n = 191) were comparable, when the condition, i.e., transplant was adjusted. The comparison curve showed differentiation in survival beyond 7 days (p < 0.01). CONCLUSIONS ACLF is a rapidly progressive disease and risk stratification within the first week of hospitalization is needed. 'Emergent LT' should be defined in the first week in the ACLF patients; the transplant window for improving survival in a live donor setting.
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Affiliation(s)
- Ashok Choudhury
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.,Department of Transplant, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rajan Vijayaraghavan
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.,Department of Transplant, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Rakhi Maiwall
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.,Department of Transplant, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Manoj Kumar
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.,Department of Transplant, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Zhongping Duan
- Translational Hepatology Institute Capital Medical University, Beijing You'an Hospital, Beijing, China
| | - Chen Yu
- Translational Hepatology Institute Capital Medical University, Beijing You'an Hospital, Beijing, China
| | - Saeed Sadiq Hamid
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Wasim Jafri
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Amna Subhan Butt
- Department of Medicine, Aga Khan University Hospital, Karachi, Pakistan
| | - Harshad Devarbhavi
- Department of Gastroenterology and Hepatology, St John Medical College, Bangalore, India
| | - Qin Ning
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ke Ma
- Department of Infectious Disease, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Soek-Siam Tan
- Department of Medicine, Hospital Selayang, Batu Caves, Selangor, Malaysia
| | - Akash Shukla
- Department of Hepatology, KEM Hospital and Seth GSMC, Mumbai, India
| | - Radhakrishna Dhiman
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ajay Duseja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Department of Hepatology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - C E Eapen
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | - Ashish Goel
- Department of Gastrointestinal Sciences, Christian Medical College, Vellore, India
| | | | - Mamun Al-Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Hasmik Ghazinyan
- Department of Hepatology, Nork Clinical Hospital of Infectious Diseases, Yerevan, Armenia
| | - Dong Joon Kim
- Centre for Liver and Digestive Diseases, Gangwon-Do, Hallym University Chuncheon Sacred Heart Hospital, Chuncheon, Republic of Korea
| | - Manoj K Sahu
- Department of Gastroenterology and Biliary Sciences, IMS and SUM Hospital, Bhubaneswar, Odisha, India
| | - Guan Huei Lee
- Department of Gastroenterology and Hepatology, National University Health System, Singapore, Singapore
| | | | | | - Samir Shah
- Department of Hepatology, Global Hospital, Mumbai, India
| | - Zaigham Abbas
- Department of Hepatogastroenterology, Ziauddin University, Karachi, Pakistan
| | - Jose D Sollano
- Department of Hepatology, Cardinal Santos Medical Centre, Manila, Philippines
| | - P N Rao
- Asian Institute of Gastroenterology, Hyderabad, India
| | | | - Gamal Shiha
- Department of Internal Medicine, Egyptian Liver Research Institute and Hospital, Cairo, Egypt
| | | | - AKadir Dokmeci
- Department of Gastroenterology, Ankara University School of Medicine, Ankara, Turkey
| | - Man Fung Yuen
- Department of Medicine, Queen Mary Hospital, The University of Hong Kong, Hong Kong, China
| | | | - Kemal Fariz Kalista
- Division of Hepatobiliary Cipto Mangunkusuamo Hospital, University of Indonesia, Jakarta, Indonesia
| | | | - George K Lau
- Department of Gastroenterology, Humanity and Health Medical Centre, Hong Kong, China
| | - Fazal Karim
- Department of Hepatology, Sir Salimullah Medical College, Dhaka, Bangladesh
| | - Priyanka Jain
- Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Guresh Kumar
- Department of Biostatistics, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Vinod Arora
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India.,Department of Transplant, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Viniyendra Pamecha
- Department of Hepatobiliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India.,Department of Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Piyush Sinha
- Department of Hepatobiliary Surgery, Institute of Liver and Biliary Sciences, New Delhi, India.,Department of Liver Transplantation, Institute of Liver and Biliary Sciences, New Delhi, India
| | - Shiv K Sarin
- Department of Hepatology, Institute of Liver and Biliary Sciences, New Delhi, 110070, India. .,Department of Transplant, Institute of Liver and Biliary Sciences, New Delhi, India.
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10
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When Is a Critically Ill Cirrhotic Patient Too Sick to Transplant? Development of Consensus Criteria by a Multidisciplinary Panel of 35 International Experts. Transplantation 2021; 105:561-568. [PMID: 32568955 DOI: 10.1097/tp.0000000000003364] [Citation(s) in RCA: 40] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND Critically ill cirrhotic patients are increasingly transplanted, but there is no consensus about futile liver transplantation (LT). Therefore, the decision to delay or deny LT is often extensively debated. These debates arise from different opinions of futility among transplant team members. This study aims to achieve a multinational and multidisciplinary consensus on the definition of futility in LT and to develop well-articulated criteria for not proceeding with LT due to futility. METHODS Thirty-five international experts from anesthesiology/intensive care, hepatology, and transplant surgery were surveyed using the Delphi method. More than 70% of similar answers to a question were necessary to define agreement. RESULTS The panel recommended patient and graft survival at 1 year after LT to define futility. Severe frailty and persistent fever or <72 hours of appropriate antimicrobial therapy in case of ongoing sepsis were considered reasons to delay LT. A simple assessment of the number of organs failing was considered the most appropriate way to decide whether LT should be delayed or denied, with respiratory, circulatory and metabolic failures having the most influence in this decision. The thresholds of severity of organ failures contraindicating LT for which a consensus was achieved were a Pao2/FiO2 ratio<150 mm Hg, a norepinephrine dose >1 μg/kg per minute and a serum lactate level >9 mmol/L. CONCLUSIONS Our expert panel provides a consensus on the definition of futile LT and on specific criteria for postponing or denying LT. A framework that may facilitate the decision if a patient is too sick for transplant is presented.
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11
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Organ allocation in the age of the algorithm: avoiding futile transplantation - utility in allocation. Curr Opin Organ Transplant 2020; 25:305-309. [PMID: 32304427 DOI: 10.1097/mot.0000000000000752] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
PURPOSE OF REVIEW This review describes and questions the evolution of allocation systems from local team decisions in the 20th century to patient-oriented allocation using complex algorithm predicting transplant benefit. RECENT FINDINGS The opening years of the 2000s have seen the implementation of prioritization scores aiming at increasing transparency and reducing waitlist mortality. The 2010s have underlined the necessity of drawing the upper limits of how sick a patient can be while still ensuring acceptable survival. More complex algorithms evaluating transplant benefit have been implemented in allocation systems to take this issue into account. SUMMARY Allocation algorithms are becoming more and more complex, integrating numerous parameters from both donor and recipient to achieve optimal matching. The limitations of implementing these complex algorithms are represented by the evermoving waiting list demography, geographic disparities between recipients and donors, team policy adaptation to rule changes, and implicit biases within the transplant community. Survival as the only metric by which to define benefit may be seen as restrictive; quality of life may be a fruitful measure for better defining benefit in organ transplantation in the future.
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12
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Caring for Cirrhotic Patients With Multiple Organ Failure in the ICU: A Change of Paradigm Is Underway. Crit Care Med 2020; 48:e842-e843. [DOI: 10.1097/ccm.0000000000004403] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
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13
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Artzner T, Michard B, Weiss E, Barbier L, Noorah Z, Merle JC, Paugam-Burtz C, Francoz C, Durand F, Soubrane O, Pirani T, Theocharidou E, O'Grady J, Bernal W, Heaton N, Salamé E, Bucur P, Barraud H, Lefebvre F, Serfaty L, Besch C, Bachellier P, Schneider F, Levesque E, Faitot F. Liver transplantation for critically ill cirrhotic patients: Stratifying utility based on pretransplant factors. Am J Transplant 2020; 20:2437-2448. [PMID: 32185866 DOI: 10.1111/ajt.15852] [Citation(s) in RCA: 77] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2019] [Revised: 01/19/2020] [Accepted: 02/27/2020] [Indexed: 01/25/2023]
Abstract
The aim of this study was to produce a prognostic model to help predict posttransplant survival in patients transplanted with grade-3 acute-on-chronic liver failure (ACLF-3). Patients with ACLF-3 who underwent liver transplantation (LT) between 2007 and 2017 in 5 transplant centers were included (n = 152). Predictors of 1-year mortality were retrospectively screened and tested on a single center training cohort and subsequently tested on an independent multicenter cohort composed of the 4 other centers. Four independent pretransplant risk factors were associated with 1-year mortality after transplantation in the training cohort: age ≥53 years (P = .044), pre-LT arterial lactate level ≥4 mml/L (P = .013), mechanical ventilation with PaO2 /FiO2 ≤ 200 mm Hg (P = .026), and pre-LT leukocyte count ≤10 G/L (P = .004). A simplified version of the model was derived by assigning 1 point to each risk factor: the transplantation for Aclf-3 model (TAM) score. A cut-off at 2 points distinguished a high-risk group (score >2) from a low-risk group (score ≤2) with 1-year survival of 8.3% vs 83.9% respectively (P < .001). This model was subsequently validated in the independent multicenter cohort. The TAM score can help stratify posttransplant survival and identify an optimal transplantation window for patients with ACLF-3.
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Affiliation(s)
- Thierry Artzner
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Baptiste Michard
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Emmanuel Weiss
- Département Anesthésie et Réanimation, AP-HP, Hôpital Beaujon, Clichy, France.,UMR S 1149 Inserm/Université Paris Diderot, Paris, France
| | - Louise Barbier
- Service de Chirurgie Digestive et Transplantation Hépatique, CHU Trousseau, Université de Tours, Tours, France.,FHU SUPORT (Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation), Strasbourg, France
| | - Zair Noorah
- Service d'Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil, France
| | - Jean-Claude Merle
- Service d'Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil, France
| | - Catherine Paugam-Burtz
- Département Anesthésie et Réanimation, AP-HP, Hôpital Beaujon, Clichy, France.,UMR S 1149 Inserm/Université Paris Diderot, Paris, France
| | - Claire Francoz
- UMR S 1149 Inserm/Université Paris Diderot, Paris, France.,Département d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - François Durand
- UMR S 1149 Inserm/Université Paris Diderot, Paris, France.,Département d'Hépatologie, AP-HP Hôpital Beaujon, Clichy, France
| | - Olivier Soubrane
- UMR S 1149 Inserm/Université Paris Diderot, Paris, France.,Service de Chirurgie Hépato-Pancréato-Biliaire, AP-HP Hôpital Beaujon, Clichy, France
| | - Tasneem Pirani
- Institute of Liver Studies, King's College Hospital, London, UK
| | | | - John O'Grady
- Institute of Liver Studies, King's College Hospital, London, UK
| | - William Bernal
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Nigel Heaton
- Institute of Liver Studies, King's College Hospital, London, UK
| | - Ephrem Salamé
- Service de Chirurgie Digestive et Transplantation Hépatique, CHU Trousseau, Université de Tours, Tours, France.,FHU SUPORT (Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation), Strasbourg, France
| | - Petru Bucur
- Service de Chirurgie Digestive et Transplantation Hépatique, CHU Trousseau, Université de Tours, Tours, France.,FHU SUPORT (Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation), Strasbourg, France
| | - Hélène Barraud
- FHU SUPORT (Fédération Hospitalo-Universitaire SUrvival oPtimization in ORgan Transplantation), Strasbourg, France.,Service d'Hépatologie, CHU Trousseau, Université de Tours, France
| | - François Lefebvre
- Service de Santé Publique, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Lawrence Serfaty
- Service d'Hépato-Gastro-Entérologie et d'Assistance Nutritive, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Camille Besch
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Philippe Bachellier
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France
| | - Francis Schneider
- Service de Réanimation Médicale, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,UMR S 1121 Inserm/Université de Strasbourg, Strasbourg, France
| | - Eric Levesque
- Service d'Anesthésie et Réanimation Chirurgicale, Hôpital Henri Mondor, Créteil, France
| | - François Faitot
- Service de Chirurgie Hépatobiliaire et Transplantation, Hôpital de Hautepierre, Hôpitaux Universitaires de Strasbourg, Strasbourg, France.,Laboratoire ICube, UMR 7357, Université de Strasbourg, Strasbourg, France
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14
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Prophylactic Anti-Cytomegalovirus Hyperimmunoglobulin in Critically Ill Liver Transplant Patients: Impact on Early Immunology and Survival. J Clin Med 2020; 9:jcm9030656. [PMID: 32121313 PMCID: PMC7141244 DOI: 10.3390/jcm9030656] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2020] [Revised: 02/15/2020] [Accepted: 02/28/2020] [Indexed: 12/22/2022] Open
Abstract
Background: Anti-cytomegalovirus hyperimmunoglobulin (CMVIg) was shown to provide beneficial immunodulatory properties beyond antiviral efficacies. The aim of this retrospective study was to assess the impact of prophylactic CMVIg treatment on early outcome following liver transplantation (LT) in critically ill patients. Methods: Forty-three cirrhotic patients requiring pre-LT intensive care due to multiorgan failure were analyzed. Twenty-eight patients with enhanced CMV risk (D+/R+; D+/R−; D−/R+) received prophylactic CMVIg for a minimum of 7 days, while 15 patients (D−/R−) did not. Results: Post-transplantation rates of intra-abdominal infections (28% vs. 61.1%; p = 0.03), Epstein–Barr virus infections (0% vs. 33.3%; p = 0.034), allograft rejections (0% vs. 22.2%; p = 0.013) and sepsis-related mortality (4% vs. 27.8%; p = 0.026) were significantly lower, whereas incidence of CMV infections (4% vs. 22.2%; p = 0.066) tended to be lower in the CMVIg subset. In multivariate analysis, only pretransplant elevated serum lactate level (hazard ratio = 34.63; p = 0.009) and absence of CMVIg therapy (hazard ratio = 21.76; p = 0.023) were identified as independent promoters of 3-month mortality. Conclusion: Prophylactic treatment with CMVIg reduces predisposition for severe immunological and septic events and, thereby, early mortality in critically ill liver recipients.
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