Liver transplantation in critically ill patients: Preoperative predictive factors of post‐transplant mortality to avoid futility

Michard, Baptiste; Artzner, Thierry; Lebas, Benjamin; Guillot, M.; Faitot, François; Lefèbvre, François; Bachellier, Philippe; Castelain, Vincent; Maestraggi, Quentin; Schneider, Francis

doi:10.1111/ctr.13115

Cited by 50 publications

(55 citation statements)

References 15 publications

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“…However, in a more recent study by Michard and colleagues, the presence of SLI as defined by a PaO 2 /FiO 2 < 200 mm Hg significantly affected post‐transplantation survival in patients with both ALF and acute on chronic liver failure (ACLF). On multivariate analysis, they found that pre‐transplant SLI (PaO 2 /FiO 2 < 200 mm Hg) was independently associated with mortality 90‐days post‐LT with a hazard ratio (HR) of 5.9 …”

Section: Discussionmentioning

confidence: 99%

“…Also, the proportion of patients with ALF and SLI listed for LT was 37.4% compared to 41.9% for patients without SLI. One reason for decreased rates of LT in patients with SLI may be that the poor predicted post‐LT survival leads to concern by the clinician or surgeon prior to surgery . Another reason may be owing to the development of cardiac and in particular right ventricular failure, which may jeopardize the newly implanted liver as a well‐recognized cause of primary graft nonfunction .…”

Section: Discussionmentioning

confidence: 99%

“…One reason for decreased rates of LT in patients with SLI may be that the poor predicted post-LT survival leads to concern by the clinician or surgeon prior to surgery. 8 Another reason may be owing to the development of cardiac and in particular right ventricular failure, which may jeopardize the newly implanted liver as a wellrecognized cause of primary graft nonfunction. 5 A study by Bozbas and colleagues also demonstrated that presence of hypoxia prior to LT was a factor associated with increased post-LT pulmonary complications, which in turn significantly affected post-LT survival.…”

Section: Discussionmentioning

confidence: 99%

“…7 High oxygen requirements can preclude ALF patients from undergoing transplantation 5 and SLI may be a predictor of post-transplant mortality in critically ill patients. 8 SLI is also associated with cerebral oedema and elevated intracranial pressures and thus increased morbidity. 9 It is thought that SLI in ALF patients leads to worse clinical outcomes, but this has not been fully quantified in the medical literature.…”

Section: Introductionmentioning

confidence: 99%

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Significant lung injury and its prognostic significance in acute liver failure: A cohort analysis

Dong

Sun

Gottfried

et al. 2019

Liver International

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Background and aims Respiratory failure complicating acute liver failure (ALF) may preclude liver transplantation (LT). We evaluated the association between significant lung injury (SLI) and important clinical outcomes. Methods Retrospective cohort study of 947 ALF patients with chest radiograph (CXR) and arterial blood gas (ABG) data enrolled in the US Acute Liver Failure Study Group (US‐ALFSG) from January 1998 to December 2016. SLI was defined by moderate hypoxaemia (Berlin classification; PaO2/FiO2 < 200 mm Hg) and abnormalities on CXR. Primary outcomes were 21‐day transplant‐free survival (TFS) and overall survival. Results Of 947 ALF patients, 370 (39%) had evidence of SLI. ALF patients with SLI (ALF‐SLI) had significantly worse oxygenation than controls on admission (median PF ratio 120 vs 300 mm Hg, P < .0001) and higher lactate (6.1 vs 4.6 mmol/l, P = .0008). ALF‐SLI patients had higher rates of tracheal (19% vs 14%) and bloodstream (17% vs 11%, P < .005 for both) infections and were more likely to receive transfusions (red cells 55% vs 43%; FFP 74% vs 66%; P < .009 for both). ALF‐SLI patients were less likely to receive LT (18% vs 25%, P = .02) and had significantly decreased 21‐day TFS (34% vs 42%) and overall survival (49% vs 64%, P < .007 for both). After adjusting for significant covariates (INR, bilirubin, acetaminophen aetiology), the development of SLI was independently associated with decreased 21‐day TFS (OR 0.71, P = .03) in ALF patients (C‐index 0.78). The incorporation of SLI improved discriminatory ability of the King's College Criteria (P = .0061) but not the ALFSG prognostic index (P = .34). Conclusion Significant lung injury is a common complication in ALF patients that adversely affects patient outcomes.

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Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Discussionmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

See 2 more Smart Citations

Significant lung injury and its prognostic significance in acute liver failure: A cohort analysis

Dong

Sun

Gottfried

et al. 2019

Liver International

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“…This is in line with a recent report that identified severe acute respiratory distress syndrome as an independent factor associated with post-transplant mortality. 118 Improvement or stabilization in OFs in the immediate pretransplant period has been associated with favourable post-LT outcomes in patients with ACLF, suggesting that the evolution of OFs should at least be controlled, if not improved, before considering an LT. 98,115 Another important point to consider is the timeframe of LT. In most studies reporting favourable post-LT outcomes in these severely ill patients, an "early" LT has been performed (time between placement on the waiting list and LT ranging from 3-9 days).…”

Section: Therapiesmentioning

confidence: 99%

Approaches for patients with very high MELD scores

Artru

Samuel

2019

JHEP Reports

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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.

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Development and Validation of a Comprehensive Model to Estimate Early Allograft Failure Among Patients Requiring Early Liver Retransplant

et al. 2020

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Key Points Question Can the individual risk estimation for early allograft failure (EAF) be improved in view of liver retransplant? Findings In this multicenter cohort study investigating the association between donor-recipient factors and EAF, a novel Early Allograft Failure Simplified Estimation (EASE) score was developed. The score includes Model for End-stage Liver Disease score, transfused packed red blood cells, and hepatic vessel early thrombosis as well as transaminases, platelet, and bilirubin kinetics as variables on day 10 after transplant. The EASE score outperformed previous model scores, estimating EAF risk with 87% accuracy on day 90 after transplant; EASE was developed on a multicenter Italian database (1609 recipients) and validated on an external UK database (538 recipients). Meaning In this study, the EASE score rated the EAF risk (0%-100%) and identified cases at unsustainable risk to be listed for retransplant.

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Liver transplantation in critically ill patients: Preoperative predictive factors of post‐transplant mortality to avoid futility

Abstract: Low lactatemia lactate level and the absence of ARDS could be useful criteria in selecting those patients in ICU who could be eligible for liver transplant.

Cited by 50 publications

References 15 publications

Significant lung injury and its prognostic significance in acute liver failure: A cohort analysis

Significant lung injury and its prognostic significance in acute liver failure: A cohort analysis

Approaches for patients with very high MELD scores

Development and Validation of a Comprehensive Model to Estimate Early Allograft Failure Among Patients Requiring Early Liver Retransplant

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