Finance, race, ethnicity, and spoken language impact clinical outcomes for children with acute liver failure.

BACKGROUND: Pediatric acute liver failure (PALF) is an emergency, necessitating prompt referral and management at an experienced liver transplant center. Social determinants of health (SDOH) drive healthcare disparities and can affect many aspects of disease presentation, access to care, and ultimately clinical outcomes. Potential associations between SDOH and PALF outcomes, including spontaneous recovery (SR), liver transplant (LT) or death, are unknown. This study aims to investigate how SDOH may affect PALF and therefore identify areas for intervention to mitigate unrecognized disparities. METHODS: A retrospective, single-center cohort was analyzed and then compared and validated with data from the multicenter National Institutes of Health PALF Study Group. The single-center review included 145 patients admitted with PALF using diagnostic codes. Medical records were reviewed to extract patient demographics, family structure, inpatient social worker assessments, and clinical outcomes. Data were stratified by outcome. RESULTS: This analysis determined that level of family support (p = .02), caretaker employment (p = .02), patient age, race, and language (p = .01) may impact clinical outcomes. Specifically, the cohort of children that died had the largest proportion of non-English speaking patients with limited support systems and parents who worked full-time. Conversely, patients who underwent LT more often belonged to English-speaking families with a homemaker and extensive support systems. CONCLUSION: This study suggests that SDOH impact PALF outcomes and highlights patient populations facing additional challenges during an already complex healthcare emergency. These associations may indicate unconscious biases held by transplant teams when evaluating waitlist candidacy, as well as barriers to healthcare access. Strategies to better understand the broader applicability of our findings and, if confirmed, efforts to mitigate social disparities, may improve clinical outcomes in PALF.

TCD assessment in fulminant hepatic failure: Improvements in cerebral autoregulation after liver transplantation.

INTRODUCTION AND OBJECTIVES: Acute liver failure, also known as fulminant hepatic failure (FHF), includes a spectrum of clinical entities characterized by acute liver injury, severe hepatocellular dysfunction and hepatic encephalopathy. The objective of this study was to assess cerebral autoregulation (CA) in 25 patients (19 female) with FHF and to follow up with seventeen of these patients before and after liver transplantation. PATIENTS AND METHODS: The mean age was 33.8 years (range 14-56, SD 13.1 years). Cerebral hemodynamics was assessed by transcranial Doppler (TCD) bilateral recordings of cerebral blood velocity (CBv) in the middle cerebral arteries (MCA). RESULTS: CA was assessed based on the static CA index (SCAI), reflecting the effects of a 20-30 mmHg increase in mean arterial blood pressure on CBv induced with norepinephrine infusion. SCAI was estimated at four time points: pretransplant and on the 1st, 2nd and 3rd posttransplant days, showing a significant difference between pre- and posttransplant SCAI (p = 0.005). SCAI peaked on the third posttransplant day (p = 0.006). Categorical analysis of SCAI showed that for most patients, CA was reestablished on the second day posttransplant (SCAI > 0.6). CONCLUSIONS: These results suggest that CA impairment pretransplant and on the 1st day posttransplant was re-established at 48-72 h after transplantation. These findings can help to improve the management of this patient group during these specific phases, thereby avoiding neurological complications, such as brain swelling and intracranial hypertension.

A Single-Center Assessment of Delayed Graft Function in Recipients of Simultaneous Liver and Kidney Transplant.

BACKGROUND: The effects of delayed graft function on long-term kidney allograft outcomes are poorly defined among simultaneous liver and kidney transplant recipients. METHODS: We analyzed data of all simultaneous liver and kidney recipients transplanted at the University of Wisconsin between 2010 and 2017. Risk factors for the development of delayed graft function, kidney graft failure, and patient mortality were outcomes of interest. RESULTS: There were a total of 60 simultaneous liver and kidney recipients; 28 (47%) had delayed graft function. After adjustment for multiple variables, we found that pretransplant dialysis >6 weeks (hazard ratio [HR] = 5.6, 95% CI: 1.23-25.59, P = .02), pretransplant albumin <3 g/dL (HR = 5.75, 95% CI: 1.76-16.94, P = .003), and presence of pretransplant diabetes (HR = 2.5, 95% CI: 0.97-4.77, P = .05) were significantly associated with delayed graft function. Multivariate analysis showed that pretransplant albumin <3 (HR = 4.86, 95% CI: 1.07-22.02, P = .02) was associated with a higher risk of all-cause kidney allograft failure, whereas the duration of delayed graft function (HR = 1.07 per day, 95% CI: 1.01-1.14, P = .01) was associated with a higher risk of death-censored kidney allograft failure. The presence of delayed graft function was not associated with all-cause or death-censored kidney or liver allograft failure. Similarly, the presence of delayed graft function was not associated with patient mortality. CONCLUSION: The incidence of delayed graft function was high in simultaneous liver and kidney recipients. However, with appropriate management, delayed graft function may not have a negative impact on patient or kidney allograft survival.

Black Adult Patients With Acute Liver Failure Are Sicker and More Likely to Undergo Liver Transplantation Than White Patients.

Racial and ethnic differences in the presentation and outcomes of patients wait-listed with acute liver failure (ALF) have not been explored. Adult patients with ALF wait-listed for liver transplantation (LT) from 2002 to 2016 were investigated using the United Network for Organ Sharing database. Clinical characteristics and causative etiologies were compared between white, black, Hispanic, and Asian patients with ALF who were wait-listed as status 1. A competing risk analysis was used to explore differences in LT and wait-list removal rates. Kaplan-Meier survival curves were used to explore differences in 1-year posttransplant survival. There were 8208 patients wait-listed with a primary diagnosis of ALF; 4501 were wait-listed as status 1 (55.3% of whites, 64.4% of blacks, 51.6% of Hispanics, 40.7% of Asians; P < 0.001). Black patients had higher bilirubin and Model for End-Stage Liver Disease at wait-listing than other groups. White patients were the most likely to have acetaminophen toxicity as a causative etiology, whereas black patients were the most likely to have autoimmune liver disease. Black patients were significantly more likely to undergo LT than white patients (hazard ratio, 1.20; 95% confidence interval, 1.08-1.30). There was no difference in wait-list removal because of death or clinical deterioration among racial/ethnic groups. The 1-year posttransplant survival was lowest in black patients (79.6%) versus white (82.8%), Hispanic (83.9%), and Asian (89.3%) patients (P = 0.02). In conclusion, etiologies of ALF vary by race and ethnicity. Black patients with ALF were more likely to be wait-listed as status 1 and undergo LT than white patients, but they were sicker at presentation. The 1-year posttransplant survival rate was lowest among black patients.

Transplante de fígado para insuficiência hepática hiperaguda relacionada à febre amarela / Liver transplant for yellow fever-related hyperacute liver failure

APRESENTAÇÃO: Algumas propostas de incorporação tecnológica no SUS são avaliadas pela CONITEC de forma simplificada, não sendo submetidas à consulta pública e/ou audiência pública. São propostas de relevante interesse público que tratam de ampliação de uso de tecnologias, nova apresentação de medicamentos ou incorporação de medicamentos com tradicionalidade de uso. Todas essas demandas envolvem tecnologias de baixo custo e baixo impacto orçamentário para o SUS e estão relacionadas à elaboração ou revisão de Protocolos Clínicos e Diretrizes Terapêuticas (PCDT). SOLICITAÇÃO DE INCORPORAÇÃO: Demandante: Secretaria de Atenção à Saúde ­ SAS. Demanda: incorporação do Transplante de Fígado para Insuficiência Hepática Hiperaguda relacionada à Febre Amarela. TRANSPLANTE DE FÍGADO: O transplante de fígado é um tipo de tratamento proposto para doenças que afetam o sistema hepatobiliar. Consiste na substituição do fígado doente por um enxerto saudável de um doador falecido, ou parte do fígado de um doador vivo. É o tratamento de escolha para um grupo de pacientes com doenças hepáticas ou biliares, para as quais as demais alternativas terapêuticas foram esgotadas e cujo uso tem potencial curativo ou de importante repercussão na qualidade de vida dos doentes. Esses transplantes estão indicados em casos de doenças hepáticas (como cirrose descompensada, polineuropatia amiloidótica familiar e câncer primário do fígado) ou biliares (como cirrose biliar primária ou secundária e atresia de vias biliares) e ainda em casos de algumas doenças metabólicas capazes de alterar gravemente a função hepatobiliar (como doença de Wilson, hemocromatose e deficiência de alfa-1-antitripsina). TRANSPLANTE DE FÍGADO EM FEBRE AMARELA: A partir do final do ano de 2017, a Coordenação-Geral do Sistema Nacional de Transplantes - CGSNT passou a observar um aumento relevante do número de inscrições em lista de espera por Insuficiência Hepática Hiperaguda - IHH. Simultaneamente, o diagnóstico de Febre Amarela ­ FA passou a ser relacionado a esse súbito crescimento, seguido da confirmação clínica e laboratorial dos casos de IHH diretamente provocados pelo agravamento da infecção pelo vírus da FA, notadamente nos mesmos estados brasileiros considerados regiões de surto epidêmico de Febre Amarela, quais sejam: Minas Gerais, Rio de Janeiro e São Paulo. Todos esses estados registraram casos de FA por meio dos sistemas de vigilância em saúde. CONSIDERAÇÕES FINAIS: De acordo com a Nota Informativa constante no processo 25000.042688/2018-63, a presente proposta de incorporação tem o objetivo de admitir temporariamente a indicação de transplante de fígado para casos de IHHFA dados os benefícios potenciais deste tratamento no restabelecimento da função hepática, a justificar sua realização de forma compassiva neste momento, e as ações para prover o estudo destes casos, com a criação do Grupo Técnico e dos procedimentos de Transplante de Fígado em Febre Amarela e Tratamento de Intercorrência em Transplante de Fígado por FA - Pós-transplante Crítico. Ressalte-se que a repercussão da insuficiência hepática no acometimento sistêmico da Febre Amarela não está bem estabelecida, e será um dos objetos do estudo multicêntrico proposto à tentativa de resposta a esta questão. Estima-se que, excluídas as contraindicações e os casos de êxito letal em lista, sejam realizados cerca de 48 (quarenta e oito) transplantes de fígado em IHHFA por ano, considerando a sazonalidade dos surtos de Febre Amarela (dezembro a maio). RECOMENDAÇÃO DA CONITEC: Os membros da CONITEC, presentes na 64ª reunião ordinária, realizada nos dias 07 e 08 de março de 2018, deliberaram, por unanimidade, recomendar a incorporação do Transplante de fígado para Insuficiência Hepática Hiperaguda ­ IHH relacionada à Febre Amarela ­ FA. Desse modo, foi assinado o Registro de Deliberação nº 346/2018. DECISÃO: PORTARIA Nº 23, DE 23 DE ABRIL DE 2019 Torna pública a decisão de incorporar o transplante de fígado para insuficiência hepática hiperaguda-IHH relacionada à febre amarela - FA, no âmbito do Sistema Único de Saúde - SUS.

Outcome of Liver Transplant Patients With High Urgent Priority: Are We Doing the Right Thing?

BACKGROUND: About 15% of liver transplantations (LTs) in Eurotransplant are currently performed in patients with a high-urgency (HU) status. Patients who have acute liver failure (ALF) or require an acute retransplantation can apply for this status. This study aims to evaluate the efficacy of this prioritization. METHODS: Patients who were listed for LT with HU status from January 1, 2007, up to December 31, 2015, were included. Waiting list and posttransplantation outcomes were evaluated and compared with a reference group of patients with laboratory Model for End-Stage Liver Disease (MELD) score (labMELD) scores ≥40 (MELD 40+). RESULTS: In the study period, 2299 HU patients were listed for LT. Ten days after listing, 72% of all HU patients were transplanted and 14% of patients deceased. Patients with HU status for primary ALF showed better patient survival at 3 years (69%) when compared with patients in the MELD 40+ group (57%). HU patients with labMELD ≥45 and patients with HU status for acute retransplantation and labMELD ≥35 have significantly inferior survival at 3-year follow-up of 46% and 42%, respectively. CONCLUSIONS: Current prioritization for patients with ALF is highly effective in preventing mortality on the waiting list. Although patients with HU status for ALF have good outcomes, survival is significantly inferior for patients with a high MELD score or for retransplantations. With the current scarcity of livers in mind, we should discuss whether potential recipients for a second or even third retransplantation should still receive absolute priority, with HU status, over other recipients with an expected, substantially better prognosis after transplantation.

Management of Pediatric Acute Liver Failure in a Region With Insufficient Deceased Donor Support: A Single-Center Experience.

OBJECTIVES: Acute liver failure is a rapidly progressive and life-threatening disease in children, whose clinical features differ from those of adults. MATERIALS AND METHODS: This is a review of a single center's experience with pediatric acute liver failure in a region with insufficient deceased donor support. The study is a retrospective review and analysis of 22 pediatric patients with acute liver failure between January 2007 and May 2013. RESULTS: The cause of acute liver failure was indeterminate in 45.4% of cases. Listing for liver transplant was required in 72.7% of patients, whereas 27.3% developed spontaneous remission. In the patients placed on the liver transplant wait list, 75% underwent liver transplant and 25% died before undergoing liver transplant. The presence of ascites, high-grade encephalopathy, and laboratory findings including high lactate dehydrogenase and phosphorous levels and international normalized ratio were significant parameters in selecting patients needing liver transplants. All liver transplants were from living donors. One- and 3-year patient survival rates after liver transplant were 75% and 75%. No serious donor complications occurred. CONCLUSIONS: Living-donor liver transplant may be the only option to save the lives of pediatric patients with acute liver failure, especially in regions with insufficient deceased-donor support. Timely referral to a multidisciplinary transplant center, expedient evaluation of living donors, and appropriate timing of transplant are crucial for a successful outcome.

The changing face of liver transplantation for acute liver failure: Assessment of current status and implications for future practice.

The etiology and outcomes of acute liver failure (ALF) have changed since the definition of this disease entity in the 1970s. In particular, the role of emergency liver transplantation has evolved over time, with the development of prognostic scoring systems to facilitate listing of appropriate patients, and a better understanding of transplant benefit in patients with ALF. This review examines the changing etiology of ALF, transplant benefit, outcomes following transplantation, and future alternatives to emergency liver transplantation in this devastating condition.

Perfil biológico y social de la población trasplantada en el hospital Garrahan por hepatitis fulminante y su relación con la evolución postrasplante / Biological and social profile of patients who underwent liver transplantation because of acute liver failure at the Garrahan Hospital

El objetivo de este estudio fue describir el perfil biológico y social del paciente pediátrico con trasplante hepático por insuficiencia hepática aguda (IHA) y la evolución postrasplante. Material y Método: trabajo retrospectivo, descriptivo y observacional, se revisaron la base de datos de 142 pacientes trasplantados por IHA desde 1992 al 2008. Se describieron los datos demográficos y sociales, indicaciones de trasplante, tipo de injerto utilizado, compatibilidad del grupo ABO, evolución pos trasplante (resultados primarios), complicaciones del trasplante y sobrevida. Resultados: El 51% de los casos de IHA fue asociado a la hepatitis infecciosa por virus A (HAV) y el 41% correspondió a las IHA indeterminadas. El 85% de la población trasplantada (120 casos) recibió un donante de tipo cadavérico (DC) y la compatibilidad de grupo ABO fue del 85%. Las complicaciones más frecuentes fueron: biliares 33 casos, infecciones bacterianas 20 casos y vasculares 13 casos. El rechazo agudo estuvo presente en 72 casos mientras que el rechazo crónico se diagnosticó en 7 casos. La sobrevida de la IHA al año del postrasplante fue del 80% y a los 5 y 10 años fue del 77%. La conciencia de enfermedad reflejada en el cumplimiento de las consignas médicos sociales estuvo presente en un 86,25%. El 70% de los padres de los niños trasplantados eran biológicos y el 52% de la población provino del área centro (Buenos Aires, Córdoba, Entre Ríos, y Santa Fe). La cobertura estuvo a cargo del estado en el 45% de la muestra (AU)

The aim of this study was to describe the social and biological profile of pediatric patients who undergo liver transplantation because of acute liver failure (ALF) and post-transplant outcome. Material and Methods: A retrospective, descriptive, and observational study was conducted. The database of 142 patients who underwent liver transplantation because of ALF between 1992 and 2008 was reviewed. Demographic and social features, indication for transplantation, type of graft used, ABO group compatibility, post-transplant outcome (primary results), complications of the transplantation and survival were evaluated. Results: ALF was associated with infectious hepatitis A (HAV) in 51% of the cases and with indeterminate ALF in 41%. Overall, 85% of the transplanted patients (120 cases) received a deceased donor (DD) organ and ABO group compatibility was 85%. Most common complications were: biliary in 33 cases, bacterial infections in 20 cases, and vascular in 13 cases. Acute rejection was observed in 72 cases while chronic rejection was diagnosed in seven cases. Oneyear post-transplant survival after ALF was 80%, while 5- and 10-year survival was 77%. Disease awareness expressed in compliance with medical and social indications was observed in 86%. Seventy percent of the parents of transplanted children were there biological parents and 52% of the population came from the central area of the country (Buenos Aires, Córdoba, Entre Ríos, y Santa Fe). Forty-five percent of the sample had public health care coverage (AU)

Use of serial assessment of disease severity and liver biopsy for indication for liver transplantation in pediatric Epstein-Barr virus-induced fulminant hepatic failure.

The decision to perform liver transplantation (LT) in patients with Epstein-Barr virus (EBV)-induced fulminant hepatic failure (FHF) relies on a precise assessment of laboratory and pathological findings. In this study, we analyzed clinical and laboratory data as well as the pathological features of the liver in order to evaluate the pathogenesis and the need for LT in 5 patients with EBV-induced FHF. According to the King's College criteria, the Acute Liver Failure Early Dynamic (ALFED) model, and the Japanese criteria (from the Acute Liver Failure Study Group of Japan), only 1 patient was considered to be a candidate for LT. However, explanted liver tissues in 3 cases exhibited massive hepatocellular necrosis together with diffuse CD8-positive T cell infiltration in both the portal area and the sinusoid. EBV was detected in the liver, plasma, and peripheral blood mononuclear cells (PBMNCs). In 2 cases indicated to be at moderate risk by the ALFED model, liver biopsy showed CD8-positive and EBV-encoded RNA signal-positive lymphocytic infiltration predominantly in the portal area, but massive hepatocellular necrosis was not observed. These patients were treated with immunosuppressants and etoposide under the diagnosis of EBV-induced hemophagocytic lymphohistiocytosis or systemic EBV-positive T cell lymphoproliferative disease of childhood. EBV DNA was detected at a high level in PBMNCs, although it was negative in plasma. On the basis of the pathological analysis of the explanted liver tissues, LT was proposed for the restoration of liver function and the removal of the EBV-infected lymphocytes concentrated in the liver. Detecting EBV DNA by a quantitative polymerase chain reaction in plasma and PBMNCs was informative. An accurate evaluation of the underlying pathogenesis is essential for developing a treatment strategy in patients with EBV-induced FHF.

Variation in access to the liver transplant waiting list in the United States.

BACKGROUND: We sought to compare liver transplant waiting list access by demographics and geography relative to the pool of potential liver transplant candidates across the United States using a novel metric of access to care, termed a liver wait-listing ratio (LWR). METHODS: We calculated LWRs from national liver transplant registration data and liver mortality data from the Scientific Registry of Transplant Recipients and the National Center for Healthcare Statistics from 1999 to 2006 to identify variation by diagnosis, demographics, geography, and era. RESULTS: Among patients with ALF and CLF, African Americans had significantly lower access to the waiting list compared with whites (acute: 0.201 versus 0.280; pre-MELD 0.201 versus 0.290; MELD era: 0.201 versus 0.274; all, P<0.0001) (chronic: 0.084 versus 0.163; pre-MELD 0.085 versus 0.179; MELD 0.084 versus 0.154; all, P<0.0001). Hispanics and whites had similar LWR in both eras (both P>0.05). In the MELD era, female subjects had greater access to the waiting list compared with male subjects (acute: 0.428 versus 0.154; chronic: 0.158 versus 0.140; all, P<0.0001). LWRs varied by three-fold by state (pre-MELD acute: 0.122-0.418, chronic: 0.092-0.247; MELD acute: 0.121-0.428, chronic: 0.092-0.243). CONCLUSIONS: The marked inequity in early access to liver transplantation underscores the need for local and national policy initiatives to affect this disparity.

Ethical dilemmas in psychiatric evaluations in patients with fulminant liver failure.

PURPOSE OF REVIEW: Fulminant hepatic failure (FHF) is one of the more dramatic and challenging syndromes in clinical medicine. Time constraints and the scarcity of organs complicate the evaluation process in the case of patients presenting with FHF, raising ethical questions related to fairness and justice. The challenges are compounded by an absence of standardized guidelines. RECENT FINDINGS: Acetaminophen overdose, often occurring in patients with histories of psychiatric illness and substance dependence, has emerged as the most common cause of FHF. The weak correlations between psychosocial factors and nonadherence, as per some studies, suggest that adherence may be influenced by systematic factors. Most research suggests that applying rigid ethical parameters in these patients, rather than allowing for case-dependent flexibility, can be problematic. SUMMARY: The decision to transplant in patients with FHF has to be made in a very narrow window of time. The time-constrained process is fraught with uncertainties and limitations, given the absence of patient interview, fluctuating medical eligibility, and limited data. Although standardized scales exist, their benefit in such settings appears limited. Predicting compliance with posttransplant medical regimens is difficult to assess and raises the question of prospective studies to monitor compliance.

Comparison of the sequential organ failure assessment score with the King's College Hospital criteria and the model for end-stage liver disease score for the prognosis of acetaminophen-induced acute liver failure.

Acetaminophen-induced acute liver failure (ALF) is a complex multiorgan illness. An assessment of the prognosis is essential for the accurate identification of patients for whom survival without liver transplantation (LT) is unlikely. The aims of this study were the comparison of prognostic models [King's College Hospital (KCH), Model for End-Stage Liver Disease, Sequential Organ Failure Assessment (SOFA), and Acute Physiology and Chronic Health Evaluation II (APACHE II)] and the identification of independent prognostic indicators of outcome. We evaluated consecutive patients with severe acetaminophen-induced ALF who were admitted to the intensive care unit. At admission, demographic, clinical, and laboratory parameters were recorded. The discriminative ability of each prognostic score at the baseline was evaluated with the area under the receiver operating characteristic curve (AUC). In addition, using a multiple logistic regression, we assessed independent factors associated with outcome. In all, 125 consecutive patients with acetaminophen-induced ALF were evaluated: 67 patients (54%) survived with conservative medical management (group 1), and 58 patients (46%) either died without LT (28%) or underwent LT (18%; group 2). Group 1 patients had significantly lower median APACHE II (10 versus 14) and SOFA scores (9 versus 12) than group 2 patients (P < 0.001). The independent indicators associated with death or LT were a longer prothrombin time (P = 0.007), the inspiratory oxygen concentration (P = 0.005), and the lactate level at 12 hours (P < 0.001). The KCH criteria had the highest specificity (83%) but the lowest sensitivity (47%), and the SOFA score had the best discriminative ability (AUC = 0.79). In conclusion, for patients with acetaminophen-induced ALF, the SOFA score performed better than the other prognostic scores, and this reflected the presence of multiorgan dysfunction. A further evaluation of SOFA with the KCH criteria is warranted.

Assessment of emergency liver transplantation criteria in acute liver failure due to Amanita phalloides.

BACKGROUND AND AIMS: The emergency liver transplantation criteria for acute liver failure (ALF) due to Amanita phalloides (A. phalloides) intoxication are not consensual. The aims of this study were to evaluate the clinical outcomes, and to assess the accuracy of the current and specific criteria for emergency liver transplantation in predicting fatal outcome in ALF induced by A. phalloides. METHODS: Ten patients admitted with ALF induced by A. phalloides in a Gastroenterology Intensive Care Unit were studied. Indications for liver transplant were based on Clichy and/or King's College criteria. Specific criteria of Ganzert and Escudié were tested retrospectively. RESULTS: A. phalloides intoxication represented 11.6% of all admissions for ALF. Patients were admitted at a mean time of 60 ± 20.4 h after ingestion. Eight patients met the Clichy and/or King's College criteria for emergency liver transplantation, seven of these patients were listed for transplant and only six patients were transplanted. Four (40%) patients died in a mean time of 4.8 ± 0.74 days after ingestion. When applied retrospectively, Escudié's criteria showed 100% of accuracy for predicting fatal outcome, whereas, King's College, Clichy's and Ganzert's criteria had an accuracy of 90, 80 and 70%, respectively. A prothrombin index of less than 10% at day 3 after ingestion showed a positive predictive value of 100% and a negative predictive value of 60%. CONCLUSION: Escudié's criteria show the best accuracy for emergency liver transplant in ALF induced by A. phalloides. The assessment of these criteria at day 3 after ingestion shows a maximum positive predictive value, although with a decline in its negative predictive value.

Cardiovascular risk assessment of the liver transplant candidate.

Liver transplantation (LT) candidates today are increasingly older, have greater medical acuity, and have more cardiovascular comorbidities than ever before. Steadily rising model for end-stage liver disease (MELD) scores at the time of transplant, resulting from high organ demand, reflect the escalating risk profiles of LT candidates. In addition to advanced age and the presence of comorbidities, there are specific cardiovascular responses in cirrhosis that can be detrimental to the LT candidate. Patients with cirrhosis requiring LT usually demonstrate increased cardiac output and a compromised ventricular response to stress, a condition termed cirrhotic cardiomyopathy. These cardiac disturbances are likely mediated by decreased beta-agonist transduction, increased circulating inflammatory mediators with cardiodepressant properties, and repolarization changes. Low systemic vascular resistance and bradycardia are also commonly seen in cirrhosis and can be aggravated by beta-blocker use. These physiologic changes all contribute to the potential for cardiovascular complications, particularly with the altered hemodynamic stresses that LT patients face in the immediate post-operative period. Post-transplant reperfusion may result in cardiac death due to a multitude of causes, including arrhythmia, acute heart failure, and myocardial infarction. Recognizing the hemodynamic challenges encountered by LT patients in the perioperative period and how these responses can be exacerbated by underlying cardiac pathology is critical in developing recommendations for the pre-operative risk assessment and management of these patients. The following provides a review of the cardiovascular challenges in LT candidates, as well as evidence-based recommendations for their evaluation and management.

Continuous peritransplant assessment of consciousness using bispectral index monitoring for patients with fulminant hepatic failure undergoing urgent liver transplantation.

BACKGROUND: Rapid deterioration of consciousness is a critical situation for patients with fulminant hepatic failure (FHF). Bispectral (BIS) index was derived from electroencephalography parameters, primarily to monitor the depth of unconsciousness. AIM: To assess the usability of peritransplant BIS monitoring in patients with FHF. METHODS: A prospective study using peritransplant BIS monitoring was performed in 26 patients with FHF undergoing urgent liver transplantation (LT). RESULTS: Pre-transplant Child-Pugh score was 12.2 +/- 1.0; model for end-stage liver disease score was 32.4 +/- 4.4; Glasgow coma score (GCS) was 9.9 +/- 1.3; and BIS index was 44.0 +/- 6.7. Pre-transplant sedation significantly decreased BIS index. After LT, all patients having endotracheal intubation recovered consciousness within one to three d and showed progressive increase in BIS index, which appeared slightly earlier and was more evident than the increase in derived GCS score. There was a significant correlation between BIS index and derived GCS scores (r(2) = 0.648). Timing of eye opening to voice was matched with BIS index of 66.3 +/- 10.4 and occurred 12.7 +/- 8.3 h after passing BIS index of 50. CONCLUSION: These results suggest that BIS monitoring is a non-invasive, simple, easy-to-interpret method, which is useful in assessing peritransplant state of consciousness. BIS monitoring may therefore be a useful tool during peritransplant intensive care for patients with FHF showing hepatic encephalopathy.

Outcome of emergency liver transplantation including mortality on the waiting list: a single-center experience.

Patients with irreversible fulminant hepatic failure (FHF) as well as recipients with primary graft nonfunction (PNF) and early hepatic artery thrombosis (HAT) die unless they undergo emergent liver transplantation (OLT). Therefore, they have the highest priority in organ allocation systems. Herein we describe our initial experience with 18 emergency among 103 OLT procedures performed in 99 adults from February 2002 through February 2007. Their diagnoses were FHF (n = 16), PNF (n = 1), and early HAT (n = 1). Ten subjects (56%) underwent emergency OLT after a mean 1.6 (range, 1 to 4) days after listing, whereas 8 (44%) patients died while awaiting a graft for a mean of 5.9 days (range, 2 to 17). All the transplants were performed according to the piggyback technique with routine preoperative use of intravenous recombinant factor VIIa (rVIIa) to control the coagulopathy, which resulted in significant (P < .0001), prompt correction of prothrombin time from a mean of 61 (range, 22 to 300) to 14 (range, 11 to 22) seconds at 15 minutes after drug administration. A mean of 4 (range, 0 to 14) units of RBC and 9 (range, 3 to 18) units of fresh frozen plasma were transfused during the procedure. Eight (80%) transplanted patients are alive in good condition with normal liver function at a mean of 18 (range, 4 to 36) months follow-up. Two patients died in the early postoperative period after massive aortic bleeding and biliary sepsis. In summary, only 56% of patients requiring emergency OLT received grafts achieving good medium and long-term survivals, which was significantly lower compared with Western European centers where this proportion reaches 90%. This outcome could be improved by international organ-sharing arrangements for emergency transplantation or living donation alternatives.

[Liver transplantation]. / Greffe de foie.

Liver transplantation is a medico-surgical treatment for patients with acute and chronic liver failure. In France, in 2005, 1024 liver transplantations have been performed, while in the same year 1691 patients were on the waiting list. Because of severe organ shortage, different approaches have been used as potential means to increase the availability of liver grafts (living donor, split, marginal grafts, non heart beating donor). In France, in 2007, the system of allocation organ will change (using a system similar to the MELD score) to prioritize patients with the highest risk of death while waiting for liver transplant.