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

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.