Limitations of current liver donor allocation systems and the impact of newer indications for liver transplantation

Abstract

Liver transplantation represents a life-saving treatment for patients with decompensated cirrhosis, a severe condition associated with a high risk of waiting list mortality. When decompensation occurs rapidly in the presence of extrahepatic organ failures, the condition is called acute-on-chronic liver failure, which is associated with an even higher risk of death, though liver transplantation can also markedly improve survival in affected patients. However, there are still gaps in our understanding of how to optimise prioritisation and organ allocation, as well as survival among patients with acute-on-chronic liver failure (both before and after transplant). Moreover, it is urgent to address inequalities in access to liver transplantation in patients with severe alcoholic hepatitis and non-alcoholic steatohepatitis. Several controversies still exist regarding gender and regional disparities, as well as the use of suboptimal donor grafts. In this review, we aim to provide a critical perspective on the role of liver transplantation in patients with decompensated cirrhosis and address areas of ongoing uncertainty.

New Indications for Liver Transplantation

“…This could lead to a more personalized approach regarding management of wait-list priority in ACLF and would ultimately improve patient's survival and LT outcomes [58].…”

“…To this end, new methods to improve assessment of LT eligibility in these patients are eagerly awaited, that is to evaluate whether an individual patient has become "too sick to be transplanted" [58,67]. The fact that no patient with ACLF and severe respiratory failure in the CANONIC trial underwent LT indicated that this condition was considered an absolute contraindication for LT in ACLF [49].…”

“…Given the increasing number of LTs performed in patients with ACLF worldwide, a better understanding of how to define too-sick-to transplant patients and thereby avoid "futile" transplantations is urgently needed [58]. Not only it is important to confirm whether LT in ACLF 3 confers a significant survival benefit, but also whether is associated with an improved quality of life [69].…”

“…In summary, in candidates awaiting LT for ACLF 3, two major variables need to be balanced to assess the best timing for transplantation, that is on one hand the individual patient's risk of progression and death on the waiting list, on the other whether there is any chance to postpone transplantation with the goal of waiting for ALCF to improve prior to LT [43,58].…”

New concepts and perspectives in decompensated cirrhosis

“…The first of these is devoted to intensive care management of these patients with extremely high attendant risk of death 12 and the second to the issues surrounding liver transplantation of patients with ACLF and multiorgan failure. 13 This is particularly challenging because of the risk of potential futility and the lack of priority for patients at risk of imminent death, as current allocation systems fail to identify these high-risk patients.…”