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

作     者：Thierry Artzner Baptiste Michard Camille Besch Eric Levesque Francois Faitot 

作者机构：Service de Renimation MeicaleHoital de HautepierreHoitaux Universitaires de StrasbourgStrasbourg 67000France Service de Chirurgie Heatobiliaire et TransplantationHoital de HautepierreHoitaux Universitaires de StrasbourgStrasbourg 67000France Service d'nestheie et Renimation ChirurgicaleHoital Henri MondorCreteil 94000France 

出 版 物：《World Journal of Gastroenterology》 (世界胃肠病学杂志（英文版）)

年 卷 期：2018年第24卷第46期

页      面：5203-5214页

核心收录：

学科分类：1002[医学-临床医学] 10[医学] 

主　　题：Liver transplantation Cirrhosis Acute on chronic liver failure Critical Intensive Ethical Intubation Organ failure Sepsis 

摘      要：Liver transplantation for critically ill cirrhotic patients with acute deterioration of liver function associated with extrahepatic organ failures is controversial. While transplantation has been shown to be beneficial on an indivi-dual basis, the potentially poorer post-transplant outcome of these patients taken as a group can be held as an argument against allocating livers to them. Although this issue concerns only a minority of liver transplants, it calls into question the very heart of the allocation paradigms in place. Indeed, most allocation algorithms have been centered on prioritizing the sickest patients by using the model for end-stage liver disease score. This has led to allocating increasing numbers of livers to increasingly critically ill patients without setting objective or consensual limits on how sick patients can be when they receive an organ. Today, finding robust criteria to deem certain cirrhotic patients too sick to be transplanted seems urgent in order to ensure the fairness of our organ allocation protocols. This review starts by fleshing out the argument that finding such criteria is essential. It examines five types of difficulties that have hindered the progress of recent literature on this issue and identifies various strategies that could be followed to move forward on this topic, taking into account the recent discussion on acute on chronic liver failure. We move on to review the literature along four axes that could guide clinicians in their decision-making process regarding transplantation of critically ill cirrhotic patients.