BackgroundTo conduct a meta-analysis with the aim of comparing the outcomes of antiviral prophylaxis and preemptive therapy for the prevention of cytomegalovirus (CMV) infection in liver transplant (LT) recipients.MethodsWe searched databases for qualified studies up until March 2022. Finally, a meta-analysis was carried out using a fixed-effect or random-effect model based on the heterogeneity.ResultsWith a total of 1834 LT patients, the pooled incidence of CMV infection and CMV disease in the overall LT recipients using antiviral prophylaxis and preemptive therapy were 24.7% vs. 40.4% and 6.4% vs. 9.4%, respectively. Our meta-analysis exhibited a significant reduction in the incidence of CMV infection due to antiviral prophylaxis when compared to preemptive therapy in the high-risk group (OR: 6.67, 95% CI: 1.73, 25.66; p = 0.006). In contrast, there was a significant reduction in the incidence of late-onset of CMV disease in preemptive therapy compared to antiviral prophylaxis in the high-risk group (OR: 0.29, 95% CI: 0.12, 0.74; p = 0.009). However, the incidence of CMV disease, allograft rejection, graft loss, drug related adverse effects, opportunistic infections and mortality did not differ significantly between both the interventions (all p> 0.05).ConclusionsWe found the use of antiviral prophylaxis, compared with preemptive therapy, is superior in controlling CMV infection and prolonging the time to CMV disease in LT recipients without an increased risk of opportunistic infections, allograft rejection, graft loss, drug related adverse effects, development of drug resistance, and mortality.
Currently, liver transplant (LT) is only the effective treatment for an acute decompensated liver. Yet, a result of LT in the background of acute decompensated liver largely depends upon the cause of decompensation. Acute-on-chronic liver failure (ACLF) should not be confused with acute liver failure (ALF), where a patient with ACLF presents with a distinct clinical feature than ALF and often requires LT as the only definitive treatment option. However, ACLF patients are generally not listed for the emergency LT due to advanced age, ongoing sepsis, multiple organ failures and active alcoholism. Then again, about 40% of the patients with ALF recover spontaneously with medical care and hence do not need LT. In between these all perplexities and contentions, it’s critical to comprehend the clinical course of liver failure. In addition, physicians should also understand when it is necessary to enlist a patient for LT and which patient are likely to get benefit from LT. Thus, utilizing a “golden window” time for LT before the development of multi-organ failure. In this chapter, we focus on the current situation of LT for ALF and ACLF and further discuss the current decision making strategies used to indicate LT in this difficult clinical scenario.
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