Copyright ©The Author(s) 2018.
World J Gastroenterol. Dec 14, 2018; 24(46): 5203-5214
Published online Dec 14, 2018. doi: 10.3748/wjg.v24.i46.5203
Table 1 Main retrospective studies on critically ill cirrhotic patients and liver transplant
AuthorStudy periodnDefinedexclusioncriteria for LTGeneral severityat LTMELDat LTPrognostic factorsofpost-transplantmortalityPost-transplant survival
Umgelter et al[12]2007-200913SubjectiveSOFA1938Increasing MELD during first 48 h and longer ICU stay46% at 1 yr
Karvelllas et al[16]2000-2009198NoSOFA 1434Not SOFA62% at 3 yr
Recipient age > 60 yr
Duan et al[27]2004-2012100NoSOFA 932LDLT = DDLT78% at 1 yr
Finkenstedt et al[9]2002-201033SubjectiveRRT 30%28No87% at 1 yr
MV 9%
Petrowsky et al[13]2002-2010133NoRRT 90%> 40MELD64% at 3 yr
Age adjusted-Charslon index
MV 66%Cardiac risk
Septic shock
Knaak et al[15]2000-2013122FiO2 > 40%SOFA 1532Glasgow Coma Score < 7 before intubation76% at 3 yr
Norepinephrine > 0.1 µg/kg per min
Levesque et al[19]2008-201330 (ACLF3)NoSOFA 1637No43% at 1 yr
Moon et al[45]1998-2010190NoRRT 43%38No70% at 5 yr
MV 36%
Artru et al[10]2008-201473 (ACLF3)No active GI bleedingSOFA 1638No84% at 1 yr
Norepinephrine < 3 mg/h
PaO2/FiO2 < 150 mmHg
Michard et al[44]2007-201555NoSOFA 1642Lactate > 5 mmol/L60% at 1 yr
ARDS with PaO2/FiO2 < 200 mmHg
Thuluvath et al[43]2002-2016677No5 or 6 OF40Age, intubation81% at 1 yr
Table 2 Potential pre-transplant prognosis factors of critically ill cirrhotic patients requiring liver transplantation
Pre-transplant organ failuresNone 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 LTPatients 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.
SepsisThe 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 patientsThere 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.