Approaches for patients with very high MELD scores

Abstract

In the era of the "sickest first" policy, patients with very high model for end-stage liver disease (MELD) scores have been increasingly admitted to the intensive care unit with the expectation that they will receive a liver transplant (LT) in the absence of improvement on supportive therapies. Such patients are often admitted in a context of acute-on-chronic liver failure with extrahepatic failures. Sequential assessment of scores or classification based on organ failures within the first days after admission help to stratify the risk of mortality in this population. Although the prognosis of severely ill cirrhotic patients has recently improved, transplant-free mortality remains high. LT is still the only curative treatment in this population. Yet, the increased relative scarcity of graft resource must be considered alongside the increased risk of losing a graft in the initial postoperative period when performing LT in "too sick to transplant" patients. Variables associated with poor immediate post-LT outcomes have been identified in large studies. Despite this, the performance of scores based on these variables is still insufficient. Consideration of a patient's comorbidities and frailty is an appealing predictive approach in this population that has proven of great value in many other diseases. So far, local expertise remains the last safeguard to LT. Using this expertise, data are accumulating on favourable post-LT outcomes in very high MELD populations, particularly when LT is performed in a situation of stabilization/improvement of organ failures in selected candidates. The absence of "definitive" contraindications and the control of "dynamic" contraindications allow a "transplantation window" to be defined. This window must be identified swiftly after admission given the poor short-term survival of patients with very high MELD scores. In the absence of any prospect of LT, withdrawal of care could be discussed to ensure respect of patient life, dignity and wishes.

Pre-transplant Biomarkers of Immune Dysfunction Improve Risk Assessment of Post-transplant Mortality Compared With Conventional Clinical Risk Scores

“…The SOFT score (14,18) and BAR score (6) were created from patient-level data from the UNOS database, which despite its statistical power, lacks granularity to capture variables of immune dysfunction and infection risk. In addition, both scores require knowledge of donor characteristics and fail to consider recipient comorbidities, which are critical risk factors considered before waitlist placement (33). For that purpose, the UCLA-FRS score was created.…”

Pre-transplant Biomarkers of Immune Dysfunction Improve Risk Assessment of Post-transplant Mortality Compared to Conventional Clinical Risk Scores

“…The SOFT score (14,18) and BAR score (6) were created from patient-level data from the UNOS database, which despite its statistical power, lacks granularity to capture variables of immune dysfunction and infection risk. In addition, both scores require knowledge of donor characteristics and fail to consider recipient comorbidities, which are critical risk factors considered before waitlist placement (34). For that purpose, the UCLA-FRS score was created.…”

Frailty as tested by the Liver Frailty Index in out-patient patients with cirrhosis in China: a cross-sectional study

“…The reasons are as follows: (1) The age of patients with cirrhosis in this study was not limited, and frailty is more common in older patients. (2) In this study, LFI was used to assess frailty in out-patient patients with cirrhosis. Frailty was affected by many factors.…”

“…Frailty is caused by decreased body reserve capacity, which can affect self-care ability and bring serious damage to the body [1]. Frailty is closely related to chronic diseases [2]. Cirrhosis is the terminal stage of various chronic liver diseases, which has a lengthy course of disease and a heavy economic burden on out-patient patients.…”