Potential catalysts in postoperative management/critical care

Abstract

1. The maturation of liver transplantation as a clinical entity has brought new challenges to intensivists. 2. Expansion of the donor pool requires increased understanding of early allograft assessment. 3. Relaxation of recipient criteria requires increases scrutiny of co-morbidities in candidate selection. 4. Technological breakthroughs offer the potential for continuous monitoring of allograft function and metabolic reserve.Living donor liver transplantation (LDLT) has evolved into a valuable tool for alleviating the organ shortage. It represents an important option for many patients who have little or no chance of receiving an organ from a deceased donor. However, LDLT is associated with a low but finite and welldocumented risk of donor morbidity and mortality. We assert that a donor death is an inevitable event for LDLT programs. Deeming it inevitable implies that a donor death must be considered a question of when and not if. LDLT programs must have specific strategies in place to ensure that such a catastrophic event is carefully anticipated and managed properly in an ethically supportable way. The interests of multiple stakeholders, at times competing, must be given focused consideration and balanced appropriately.It is important to note that the deaths of living liver donors have generated far more media coverage than the deaths of living kidney donors. Because liver donor deaths have been such a lightning rod and have attracted so much attention, organizations with LDLT programs have to be especially prepared.Liver transplantation (LT) has demonstrated an extraordinary evolution over the past 25 years. Advances in immunosuppression, medical management, surgical technique, donor selection, and recipient identification have transformed this procedure from a feat reserved for select medical centers into the universal standard of care. As the field has matured, success has resulted in further expansion of donor as well as recipient selection criteria. For example, the percentage of recipients over 65 years of age at LT has increased by over 80% since 2000. 1 Looking forward, today's success in treating hepatitis C will accelerate inherent declines in incidence and prevalence, resulting in a significant reduction in the need for LT. However, a new epidemic is emerging with the potential to dwarf the demands of hepatitis C. Nonalcoholic steatohepatitis (NASH) is exponentially emerging as an etiology of cirrhosis and is predicted to become a leading indication for LT. 2 NASH is a challenge to the LT community not only in its absolute magnitude but also in its strong association with comorbidities that directly affect surgical outcomes, its broader age range at presentation, and its decreased correlation with Model for End-Stage Liver Disease (MELD) score as a predictor of mortality. To date, limited data support excellent outcomes for LT in select cohorts of high-bodymass-index recipients. 3 However, as NASH expands to represent a larger percentage of potential recipients, their physiological challenges will t...