Original Article
Copyright ©2013 Baishideng Publishing Group Co., Limited. All rights reserved.
World J Hepatol. Jan 27, 2013; 5(1): 26-32
Published online Jan 27, 2013. doi: 10.4254/wjh.v5.i1.26
Outcomes following liver transplantation in intensive care unit patients
Lena Sibulesky, Michael G Heckman, C Burcin Taner, Juan M Canabal, Nancy N Diehl, Dana K Perry, Darren L Willingham, Surakit Pungpapong, Barry G Rosser, David J Kramer, Justin H Nguyen
Lena Sibulesky, C Burcin Taner, Juan M Canabal, Dana K Perry, Darren L Willingham, Surakit Pungpapong, Barry G Rosser, David J Kramer, Justin H Nguyen, Department of Transplantation, Mayo Clinic, Jacksonville, FL 32225, United States
Michael G Heckman, Nancy N Diehl, Biostatistics Unit, Mayo Clinic, Jacksonville, FL 32225, United States
Michael G Heckman, Departments of Transplantation and Critical Care Medicine, Mayo Clinic, Jacksonville, FL 32225, United States
Darren L Willingham, Department of Critical Care Medicine and Internal Medicine, Aurora Health Care, Milwaukee, WI 53204, United States
Author contributions: Sibulesky L, Canabal JM and Kramer DJ contributed to direct participation in the study, including substantial contributions to conception and design of study, or acquisition of data, or analysis and interpretation of data; Sibulesky L, Heckman MG, Taner CB, Canabal JM, Perry DK, Willingham DL, Pungpapong S, Rosser BG, Kramer DJ and Nguyen JH contributed to manuscript writing, including drafting the article, or revising it critically for important intellectual content; Heckman MG and Diehl NN contributed to supportive work, including statistical analysis of data, or acquisition of funding, or administration, technology and materials support, or supervision, or supportive contributions.
Correspondence to: Lena Sibulesky, MD, Department of Transplantation, Mayo Clinic, 4500 San Pablo Road, Jacksonville, FL 32224, United States. sibulesky.lena@mayo.edu
Telephone: +1-904-9563261 Fax: +1-904-9563359
Received: July 10, 2012
Revised: September 8, 2012
Accepted: November 14, 2012
Published online: January 27, 2013

AIM: To determine feasibility of liver transplantation in patients from the intensive care unit (ICU) by estimating graft and patient survival.

METHODS: This single center retrospective study included 39 patients who had their first liver transplant directly from the intensive care unit and 927 non-ICU patients who were transplanted from hospital ward or home between January 2005 and December 2010.

RESULTS: In comparison to non-ICU patients, ICU patients had a higher model for end-stage liver disease (MELD) at transplant (median: 37 vs 20, P < 0.001). Fourteen out of 39 patients (36%) required vasopressor support immediately prior to liver transplantation (LT) with 6 patients (15%) requiring both vasopressin and norepinephrine. Sixteen ICU patients (41%) were ventilator dependent immediately prior to LT with 9 patients undergoing percutaneous tracheostomy prior to transplantation. Twenty-five ICU patients (64%) required dialysis preoperatively. At 1, 3 and 5 years after LT, graft survival was 76%, 68% and 62% in ICU patients vs 90%, 81% and 75% in non-ICU patients. Patient survival at 1, 3 and 5 years after LT was 78%, 70% and 65% in ICU patients vs 94%, 85% and 79% in non-ICU patients. When formally comparing graft survival and patient survival between ICU and non-ICU patients using Cox proportional hazards regression models, both graft survival [relative risk (RR): 1.94, 95%CI: 1.09-3.48, P = 0.026] and patient survival (RR: 2.32, 95%CI: 1.26-4.27, P = 0.007) were lower in ICU patients vs non-ICU patients in single variable analysis. These findings were consistent in multivariable analysis. Although not statistically significant, graft survival was worse in both patients with cryptogenic cirrhosis (RR: 3.29, P = 0.056) and patients who received donor after cardiac death (DCD) grafts (RR: 3.38, P = 0.060). These findings reached statistical significance when considering patient survival, which was worse for patients with cryptogenic cirrhosis (RR: 3.97, P = 0.031) and patients who were transplanted with DCD livers (RR: 4.19, P = 0.033). Graft survival and patient survival were not significantly worse for patients on mechanical ventilation (RR: 0.91, P = 0.88 in graft loss; RR: 0.69, P = 0.56 in death) or patients on vasopressors (RR: 1.06, P = 0.93 in graft loss; RR: 1.24, P = 0.74 in death) immediately prior to LT. Trends toward lower graft survival and patient survival were observed for patients on dialysis immediately before LT, however these findings did not approach statistical significance (RR: 1.70, P = 0.43 in graft loss; RR: 1.46, P = 0.58 in death).

CONCLUSION: Although ICU patients when compared to non-ICU patients have lower survivals, outcomes are still acceptable. Pre-transplant ventilation, hemodialysis, and vasopressors were not associated with adverse outcomes.

Keywords: Donor pool, Donor outcomes, Onor after cardiac death grafts, Liver graft survival, Patient survival