Liver transplantation in acute liver failure: Dilemmas and challenges

Abstract

Acute liver failure (ALF) refers to a state of severe hepatic injury that leads to altered coagulation and sensorium in the absence of pre-existing liver disease. ALF has different causes, but the clinical characteristics are strikingly similar. In clinical practice, however, inconsistency in the definition of ALF worldwide and confusion regarding the existence of pre-existing liver disease raise diagnostic dilemmas. ALF mortality rates used to be over 80% in the past; however, survival rates on medical treatment have significantly improved in recent years due to a greater understanding of pathophysiology and advances in critical care management. The survival rates in acetaminophen-associated ALF have become close to the post-transplant survival rates. Given that liver transplantation (LT) is an expensive treatment that involves a major surgical operation in critically ill patients and lifelong immunosuppression, it is very important to select accurate patients who may benefit from it. Still, emergency LT remains a lifesaving procedure for many ALF patients. However, there is a lack of consistency in current prognostic models that hampers the selection of transplant candidates in a timely and precise manner. The other problems associated with LT in ALF are the shortage of graft, development of contraindications on the waiting list, vaguely defined delisting criteria, time constraints for pre-transplant evaluation, ethical concerns, and comparatively poor post-transplant outcomes in ALF. Therefore, there is a desperate need to establish accurate prognostic models and explore the roles of evolving adjunctive and alternative therapies, such as liver support systems, plasma exchange, stem cells, auxiliary LT, and so on, to enhance transplant-free survival and to fill the void created by the graft shortage

Economic Evaluations of Liver Transplantation as Tools for Decision-Making and Implications in Clinical Practice

“…Kumar et al [66] in their study indicate that some other causes of the increase in these costs may be associated with the development of complications in the immediate postoperative period, with infections being the most common, the development of complications is also associated with the etiology for which the transplant was performed, finding better results in those patients with Wilson's disease versus those who presented acute liver failure due to acetaminophen [66].…”

“…This is demonstrated by some studies. Kumar et al [66] mention that these rates in the patient transplanted for acute liver disease are around 80% at the first year and 75% at 5 years, while Roberts et al [67] indicate that for patients transplanted for any other cause, these rates are at 85% per year and 74% at 5 years.…”

“…Something to consider is that the transplant itself already generates an increase in expenses, since Kumar et al [66] in their study were able to demonstrate that the costs at days 30, 60, and 365 after a liver transplant versus standard care (that is, in a nontransplanted patient) are 5 times higher, as an example, per year the costs in transplantation were calculated at $ 198,000 against $48,000 in the non-transplanted [66].…”

The role of platelet mediated thromboinflammation in acute liver injury

“…Ten percent of liver transplants in the West are due to acute liver failure ( 1 ). Dilemmas surrounding timing of liver transplantation, prognosis and donor shortage highlight the need for disease modifying treatments in patients with ALF ( 3 ).…”

The Role of NLRP3 Inflammasome Activation Pathway of Hepatic Macrophages in Liver Ischemia–Reperfusion Injury

“…At present, liver transplantation (LT) is widely used as the most effective and definitive treatment for end-stage liver diseases, hepatic malignancies, acute fulminant hepatic failure, and metabolic disorders (13). During the LT surgery, the cell death in donor liver was exacerbated following the restoration of oxygen delivery.…”