When Is a Critically Ill Cirrhotic Patient Too Sick to Transplant? Development of Consensus Criteria by a Multidisciplinary Panel of 35 International Experts.

BACKGROUND: Critically ill cirrhotic patients are increasingly transplanted, but there is no consensus about futile liver transplantation (LT). Therefore, the decision to delay or deny LT is often extensively debated. These debates arise from different opinions of futility among transplant team members. This study aims to achieve a multinational and multidisciplinary consensus on the definition of futility in LT and to develop well-articulated criteria for not proceeding with LT due to futility. METHODS: Thirty-five international experts from anesthesiology/intensive care, hepatology, and transplant surgery were surveyed using the Delphi method. More than 70% of similar answers to a question were necessary to define agreement. RESULTS: The panel recommended patient and graft survival at 1 year after LT to define futility. Severe frailty and persistent fever or <72 hours of appropriate antimicrobial therapy in case of ongoing sepsis were considered reasons to delay LT. A simple assessment of the number of organs failing was considered the most appropriate way to decide whether LT should be delayed or denied, with respiratory, circulatory and metabolic failures having the most influence in this decision. The thresholds of severity of organ failures contraindicating LT for which a consensus was achieved were a Pao2/FiO2 ratio<150 mm Hg, a norepinephrine dose >1 µg/kg per minute and a serum lactate level >9 mmol/L. CONCLUSIONS: Our expert panel provides a consensus on the definition of futile LT and on specific criteria for postponing or denying LT. A framework that may facilitate the decision if a patient is too sick for transplant is presented.

Adapting the Surgical Apgar Score for Perioperative Outcome Prediction in Liver Transplantation: A Retrospective Study.

BACKGROUND: The surgical Apgar score (SAS) is a 10-point scale using the lowest heart rate, lowest mean arterial pressure, and estimated blood loss (EBL) during surgery to predict postoperative outcomes. The SAS has not yet been validated in liver transplantation patients, because typical blood loss usually exceeds the highest EBL category. Our primary aim was to develop a modified SAS for liver transplant (SAS-LT) by replacing the EBL parameter with volume of red cells transfused. We hypothesized that the SAS-LT would predict death or severe complication within 30 days of transplant with similar accuracy to current scoring systems. METHODS: A retrospective cohort of consecutive liver transplantations from July 2007 to November 2013 was used to develop the SAS-LT. The predictive ability of SAS-LT for early postoperative outcomes was compared with Model for End-stage Liver Disease, Sequential Organ Failure Assessment, and Acute Physiology and Chronic Health Evaluation III scores using multivariable logistic regression and receiver operating characteristic analysis. RESULTS: Of 628 transplants, death or serious perioperative morbidity occurred in 105 (16.7%). The SAS-LT (receiver operating characteristic area under the curve [AUC], 0.57) had similar predictive ability to Acute Physiology and Chronic Health Evaluation III, model for end-stage liver disease, and Sequential Organ Failure Assessment scores (0.57, 0.56, and 0.61, respectively).Seventy-nine (12.6%) patients were discharged from the ICU in 24 hours or less. These patients' SAS-LT scores were significantly higher than those with a longer stay (7.0 vs 6.2, P < 0.01). The AUC on multivariable modeling remained predictive of early ICU discharge (AUC, 0.67). CONCLUSIONS: The SAS-LT utilized simple intraoperative metrics to predict early morbidity and mortality after liver transplant with similar accuracy to other scoring systems at an earlier postoperative time point.

The perioperative management of patients undergoing combined heart-liver transplantation.

BACKGROUND: Combined heart-liver transplantation (CHLT) is an uncommonly performed procedure for patients with coexisting cardiac and liver disease. METHODS: A retrospective review was performed of patients undergoing CHLT at our institution from 1999 to 2013. Information related to preoperative organ function, intraoperative management, surgical approach, transfusions, postoperative findings, and 30-day mortality was reviewed. RESULTS: Twenty-seven CHLT were performed, with 4 of the 27 including simultaneous kidney transplantation. Familial amyloidosis was the indication for 21 CHLTs (78%), and 12 of these explanted livers were used for domino transplantations. Nineteen patients (70%) were receiving inotropic infusions at the time of organ availability. Median preoperative model for end-stage liver disease score was 12. Liver transplantation immediately preceded cardiac transplantation in 2 of the 27 cases because of the presence of high titer donor-specific antibodies and the potential of the liver to lead to a reduction in the antibody titer. Venovenous bypass was used in 14 operations (52%) which were performed with the caval interposition approach to liver transplantation, cardiopulmonary bypass during liver transplantation in two cases (7%), and no bypass in 11 operations (41%) performed with caval sparing (piggyback) surgical technique. Postoperatively, median duration of mechanical ventilation, intensive care unit stay, and hospital stay until discharge were 1 day, 5.5 days, and 15 days, respectively. Transfusions in the first 48 hr after CHLT were not substantial in most patients. One patient died within 30 days of CHLT. CONCLUSION: Combined heart-liver transplantation is a life-saving operation that is performed with relatively low mortality and can be successfully performed in select patients with congenital or acquired cardiac disease.

Patient selection and preoperative evaluation for transplant surgery.

Candidates for abdominal transplant undergo a pretransplant evaluation to identify associated conditions that may require intervention or that may influence a patient's candidacy for transplant. Coronary artery disease is prevalent in candidates for abdominal organ transplantation. The optimal approach to identify and manage coronary artery disease in the peri-transplant period is currently unclear. In liver transplant candidates portopulmonary hypertension and hepatopulmonary syndrome should be screened for. Identification of the patient who is too sick to benefit from transplant is problematic; with no good evidence available decisions should be individualized and made after multidisciplinary discussion.

Changes in transfusion practice over time in adult patients undergoing liver transplantation.

OBJECTIVE: The aim of this study was to investigate changes in transfusion practice over time in liver transplantation surgery and to evaluate potential causes for changes in practice and report associated perioperative morbidity and mortality. DESIGN: A retrospective cohort study. SETTING: A single tertiary referral academic hospital. PARTICIPANTS: Two cohorts of 100 sequential adult primary liver transplant recipients: Early practice (1990-1991) and recent practice (2005-2006). INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Perioperative transfusion and hemoglobin data were recorded. Mortality and postoperative complications were identified up to 30 days postoperatively. Appropriate intergroup statistical comparisons were made; p ≤ 0.05 was considered statistically significant. Compared with the early group, the recent group had significantly fewer perioperative allogeneic red blood cell transfusions, intraoperative autotransfusions, and transfusions of other blood products. No change in perioperative transfusion triggers was identified. There were no significant alterations in perioperative morbidity or mortality. CONCLUSIONS: When compared with patients in the early group, recent cohort patients received significantly fewer blood transfusions. The authors attribute this observation to changes in surgical technique rather than a significant alteration in transfusion triggers over the studied time period.

APACHE III outcome prediction in patients admitted to the intensive care unit after liver transplantation: a retrospective cohort study.

BACKGROUND: The Acute Physiology and Chronic Health Evaluation (APACHE) III prognostic system has not been previously validated in patients admitted to the intensive care unit (ICU) after orthotopic liver transplantation (OLT). We hypothesized that APACHE III would perform satisfactorily in patients after OLT METHODS: A retrospective cohort study was performed. Patients admitted to the ICU after OLT between July 1996 and May 2008 were identified. Data were abstracted from the institutional APACHE III and liver transplantation databases and individual patient medical records. Standardized mortality ratios (with 95% confidence intervals) were calculated by dividing the observed mortality rates by the rates predicted by APACHE III. The area under the receiver operating characteristic curve (AUC) and the Hosmer-Lemeshow C statistic were used to assess, respectively, discrimination and calibration of APACHE III. RESULTS: APACHE III data were available for 918 admissions after OLT. Mean (standard deviation [SD]) APACHE III (APIII) and Acute Physiology (APS) scores on the day of transplant were 60.5 (25.8) and 50.8 (23.6), respectively. Mean (SD) predicted ICU and hospital mortality rates were 7.3% (15.4) and 10.6% (18.9), respectively. The observed ICU and hospital mortality rates were 1.1% and 3.4%, respectively. The standardized ICU and hospital mortality ratios with their 95% C.I. were 0.15 (0.07 to 0.27) and 0.32 (0.22 to 0.45), respectively. There were statistically significant differences in APS, APIII, predicted ICU and predicted hospital mortality between survivors and non-survivors. In predicting mortality, the AUC of APACHE III prediction of hospital death was 0.65 (95% CI, 0.62 to 0.68). The Hosmer-Lemeshow C statistic was 5.288 with a p value of 0.871 (10 degrees of freedom). CONCLUSION: APACHE III discriminates poorly between survivors and non-survivors of patients admitted to the ICU after OLT. Though APACHE III has been shown to be valid in heterogenous populations and in certain groups of patients with specific diagnoses, it should be used with caution - if used at all - in recipients of liver transplantation.

Right hepatectomy for living liver donation vs right hepatectomy for disease: intraoperative and immediate postoperative comparison.

HYPOTHESIS: Perioperative events of patients undergoing living donor (LD) right hepatectomy are similar to those of patients undergoing right hepatectomy for disease (DZ). DESIGN: Institutional review board-approved retrospective case-control study. SETTING: Eight hundred-bed tertiary care referral center. PATIENTS AND METHODS: We matched 40 patients who had LD with 40 patients who had DZ. Perioperative events (anesthesia, surgical events, transfusion, hemodynamic events, complications, and length of hospital stay) were compared using the signed rank test and exact McNemar test where appropriate. MAIN OUTCOME MEASURES: Intraoperative time, transfusion requirements, postoperative complications, and hospital length of stay. RESULTS: There was a significant difference in surgical time between the LD and DZ groups (median, 4.1 vs 3.3 hours; P = .001). There was also a significant difference in anesthesia time between the LD and DZ groups (median, 5.6 vs 4.2 hours; P<.001). The level of autologous transfusion was higher in the LD group (median, 1.3 vs 0 U in the DZ group; P<.001), and that of packed red blood cell transfusion was lower in the LD group (mean, 0 vs 0.5 U; P = .008). There was no other significant intraoperative difference. Postoperative hemoglobin levels were significantly higher in the LD group (median, 12.6 vs 11.8 g/dL; P = .03). Comparison of the number of complications in the immediate postoperative period revealed no other significant differences. CONCLUSIONS: The LD procedure took longer to perform because of the time required for hilar dissection. The difference in intraoperative transfusions is attributable to use of cell salvage and retransfusion of salvaged blood for all donors; this was not routine for DZ procedures. Perioperative outcomes were similar in all other respects. The LD procedure has similar outcomes to those of the DZ procedure.

Aprotinin reduces vasoactive medication use during adult liver transplantation.

STUDY OBJECTIVE: To determine whether aprotinin use during adult liver transplantation results in an improvement in hemodynamic stability. DESIGN: Review of data collected during a prospective, randomized, double-blind trial. SETTING: Liver transplantation program in a tertiary referral institution. PATIENTS: 63 adult patients undergoing orthotopic liver transplantation (OLT). INTERVENTIONS: Patients were randomized to receive either aprotinin (1,000,000 KIU loading dose, followed by an infusion of 250,000 KIU/hr) for the duration of the surgery or a placebo infusion (normal saline). MEASUREMENTS: Hemodynamic parameters (mean systemic blood pressure, cardiac output, systemic vascular resistance, mean pulmonary artery (PA) pressure, and PA occlusion pressure) were compared at set time points during the procedure. The use of vasoactive medications during and after the reperfusion period was compared. MAIN RESULTS: There were no significant differences in any of the measured hemodynamic parameters at any time point. Vasoactive infusions were used in 1 of 33 patients in the aprotinin group and in 6 of 30 patients in the control group (p < 0.05). Bolus doses of pressor medications during the recirculation period did not differ between groups. CONCLUSION: Aprotinin infusion during adult liver transplantation results in less requirement for vasoactive intervention.