Liver transplantation for critically ill cirrhotic patients: Overview and pragmatic proposals

Abstract

Liver transplantation for critically ill cirrhotic patients with acute deterioration of liver function associated with extrahepatic organ failures is controversial. While transplantation has been shown to be beneficial on an individual basis, the potentially poorer post-transplant outcome of these patients taken as a group can be held as an argument against allocating livers to them. Although this issue concerns only a minority of liver transplants, it calls into question the very heart of the allocation paradigms in place. Indeed, most allocation algorithms have been centered on prioritizing the sickest patients by using the model for end-stage liver disease score. This has led to allocating increasing numbers of livers to increasingly critically ill patients without setting objective or consensual limits on how sick patients can be when they receive an organ. Today, finding robust criteria to deem certain cirrhotic patients too sick to be transplanted seems urgent in order to ensure the fairness of our organ allocation protocols. This review starts by fleshing out the argument that finding such criteria is essential. It examines five types of difficulties that have hindered the progress of recent literature on this issue and identifies various strategies that could be followed to move forward on this topic, taking into account the recent discussion on acute on chronic liver failure. We move on to review the literature along four axes that could guide clinicians in their decision-making process regarding transplantation of critically ill cirrhotic patients.

Keywords: Liver transplantation; Cirrhosis; Acute on chronic liver failure; Critical; Intensive; Ethical; Intubation; Organ failure; Sepsis

Core tip: Liver transplantation (LT) for critically ill cirrhotic patients is a controversial topic. While transplantation benefits these patients individually, the post-transplant mortality rate of this population taken as a whole is an argument against transplanting them. This issue is particularly pressing in a time when the paradigm dominating LT algorithms is based on the model for end-stage liver disease score, which prioritizes the sickest patients. Balancing individual benefits against collective utility is complex, especially given the absence of guidelines. This review examines the literature that can guide clinicians who treat critically ill patients and who decide to transplant them or not.