Critical care management of the patient with cirrhosis awaiting liver transplant in the intensive care unit

Abstract

Patients with cirrhosis who are awaiting liver transplantation (LT) are at high risk for developing critical illnesses. Current liver allocation policies that dictate a "sickest first" approach coupled with a mismatch between need and availability of organs result in longer wait times, and thus, patients are becoming increasingly ill while awaiting organ transplantation. Even patients with well-compensated cirrhosis may suffer acute deterioration; the syndrome of acute-on-chronic liver failure (ACLF) results in multisystem organ dysfunction and a marked increase in associated short-term morbidity and mortality. For patients on transplant waiting lists, the development of multisystem organ failure may eliminate candidacy for transplant by virtue of being "too sick" to safely undergo transplantation surgery. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (eg, infection and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo LT. Management of the critically ill ACLF patient awaiting transplantation is best accomplished by multidisciplinary teams with expertise in critical care and transplant medicine. Such teams are well suited to address the needs of this unique patient population and to identify patients who may be too ill to proceed to transplantation surgery. The focus of this review is to identify the common complications of ACLF and to describe our approach management in critically ill patients awaiting LT in our centers. Liver Transplantation 23 1465-1476 2017 AASLD.

Fibroblast growth factor 21 is an early predictor of acute‐on‐chronic liver failure in critically ill patients with cirrhosis

“…Moreover, the clinical course of patients admitted to the hospital seems to be important for the prognosis, especially because development of ACLF presents a major crossroad in the clinical evolution and therefore management of the patients . In critically ill patients with cirrhosis, diagnosis of ACLF could play an important role in the timing of several therapeutic decisions, such as renal replacement therapy, plasma exchange, artificial liver support, and liver transplantation . Therefore, early diagnosis of patients with AD, who will develop ACLF after admission to the intensive care unit (ICU), is crucial …”

“…In critically ill patients with cirrhosis, diagnosis of ACLF could play an important role in the timing of several therapeutic decisions, such as renal replacement therapy, plasma exchange, artificial liver support, and liver transplantation . Therefore, early diagnosis of patients with AD, who will develop ACLF after admission to the intensive care unit (ICU), is crucial …”

Patient With Nonalcoholic Steatohepatitis Posttransplant Develops Acute Hepatitis B Virus Causing Graft Failure

“…ALF is a rare but fatal complication of severe liver injury . The incidence in developed countries is less than 10 cases per million people per year .…”

Acute (Not Decompensation)-on-Chronic Liver Failure

“…It would have been interesting to better characterize these cases of positive prognosis, with and without hepatic transplantation, such as grade and/or CLIF/SOFA score at entry and its evolution (day 3 and day 7). Often our daily decisions may lead to therapeutic futility, namely which patients with grade 3 ACLF would have been considered or not too sick to benefit from a liver transplant [6] .…”