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

Table 1 Main retrospective studies on critically ill cirrhotic patients and liver transplant

Author	Study period	n	Definedexclusioncriteria for LT	General severityat LT	MELDat LT	Prognostic factorsofpost-transplantmortality	Post-transplant survival
Umgelter et al[12]	2007-2009	13	Subjective	SOFA19	38	Increasing MELD during first 48 h and longer ICU stay	46% at 1 yr
Karvelllas et al[16]	2000-2009	198	No	SOFA 14	34	Not SOFA	62% at 3 yr
						Recipient age > 60 yr
Duan et al[27]	2004-2012	100	No	SOFA 9	32	LDLT = DDLT	78% at 1 yr
Finkenstedt et al[9]	2002-2010	33	Subjective	RRT 30%	28	No	87% at 1 yr
				MV 9%
Petrowsky et al[13]	2002-2010	133	No	RRT 90%	> 40	MELD	64% at 3 yr
						Age adjusted-Charslon index
				MV 66%		Cardiac risk
						Septic shock
Knaak et al[15]	2000-2013	122	FiO2 > 40%	SOFA 15	32	Glasgow Coma Score < 7 before intubation	76% at 3 yr
			Norepinephrine > 0.1 µg/kg per min
Levesque et al[19]	2008-2013	30 (ACLF3)	No	SOFA 16	37	No	43% at 1 yr
Moon et al[45]	1998-2010	190	No	RRT 43%	38	No	70% at 5 yr
				MV 36%
Artru et al[10]	2008-2014	73 (ACLF3)	No active GI bleeding	SOFA 16	38	No	84% at 1 yr
			Norepinephrine < 3 mg/h
			PaO2/FiO2 < 150 mmHg
Michard et al[44]	2007-2015	55	No	SOFA 16	42	Lactate > 5 mmol/L	60% at 1 yr
						ARDS with PaO2/FiO2 < 200 mmHg
Thuluvath et al[43]	2002-2016	677	No	5 or 6 OF	40	Age, intubation	81% at 1 yr

LT: Liver transplant; SOFA: Sequential organ failure assessment; ICU: Intensive care unit; RRT: Renal replacement therapy; MV: Mechanical ventilation; ARDS: Acute respiratory distress syndrome; DDLT/LDLT: Deceased/living donor liver transplantation; GI: Gastro intestinal; MELD: Model for end-stage liver disease; OF: Organ failure according to CLIF-SOFA.

Table 2 Potential pre-transplant prognosis factors of critically ill cirrhotic patients requiring liver transplantation

Pre-transplant organ failures	None of the existing organ failure scores used in liver transplant (MELD, BAR, SOFT, UCLA) or in ICU (SOFA, CLIF SOFA) are capable of predicting post-transplant survival of critically ill ACLF patients
	Individual organ failures should be precisely examined. Severe acute respiratory distress syndrome, high lactate level and coma have each been shown to be associated with poor post-transplant outcome
Dynamic perspective on ACLF and optimal timing for LT	Patients with ACLF have very different evolutive profiles during their first week of treatment.
	Admission criteria in ICU should therefore be lenient in order to re-evaluate patients 3 to 7 d after admission and their evolutive profile should be taken into consideration when deciding to transplant them or not.
Sepsis	The link between pre-transplant bacterial infection and post-transplant mortality is controversial but sepsis does not seem to be sufficient to exclude patients from LT per se. In some circumstances, sepsis and septic shock can be difficult to distinguish from SIRS in patients with severe ACLF.
	By contrast, there is a consensus regarding invasive fungal infections, which constitutes a strict contraindication to LT.
General medical condition and risk factors of patients	There is little data on the effect of age, comorbidities and alcohol abuse history on the post-transplant prognosis of patients with severe ACLF, in part because different transplant teams apply center-specific selection criteria on patients prior to listing.
	The attitude described in the literature on LT in alcoholic hepatitis is, to date, the best guide to decide as early as possible whether to (de) list patients admitted for severe ACLF or not.

LT: Liver transplantation; MELD: Model for end-stage liver disease; BAR: Balance of risk; SOFT: Survival outcome following liver transplantation; UCLA: University of California, Los Angeles; ICU: Intensive care unit; SOFA: Sequential organ failure assessment; ACLF: Acute-on-chronic liver failure; SIRS: Systemic inflammatory response syndrome.