![]() iMELD, UKELD, MELD-AS, CTP, and mCTP) in predicting the post-transplant mortality, we analyzed the data of 6,014 adult cirrhotic patients who underwent liver transplantation between January 2003 and December 2010 from the China Liver Transplant Registry database. ACLF, acute-on-chronic liver failure LT, liver transplantation GI, gastrointestinal.To compare the performance of eight score systems (MELD, uMELD, MELD-Na. other bacterial infection such as ventilation associated pneumonia, GI bleeding) can occur and lead patient to death. If, the opportunity to transplant is not taken during the firsts transplantation windows, other events ( e.g. ![]() metastatic neoplasia, severe cardiac insufficiency). In these (often) short elapsed time in patient who were not already listed health assessment should be performed in order to exclude “definitive” contraindication to LT ( e.g. After their resolution (or at least control – depending on local expertise) “dynamic” contraindications are separated by transplantation windows (green boxes) if LT is indicated. severe acute respiratory syndrome with hemodynamic instability). The “dynamic” contraindications (red boxes) illustrate a timeframe in which LT should not be performed due to uncontrolled clinical condition ( e.g. In this scenario, the onset of a precipitating event (bacterial pneumonia for example) leads to a rapid deterioration of liver function and ACLF in a patient with chronic liver disease. Y axis illustrates “liver function” and X axis “time”. 3 Illustration of "transplantation window" and "dynamic contraindication" relationship. ![]() Several unmet medical and ethical issues have to be faced by clinicians in order to optimize management of patients with very high MELD scores from the perspective of LT, such as: How should these patients be categorized in the era of the dual concepts of acute-on-chronic liver failure (ACLF) and “mere” acute decompensation? Which prognosis assessment should be used? In the context of permanent scarcity of resource, how should the priority access to LT be managed in the most severely ill patients given the potential increased risk of post-LT mortality? Can upper limits of sickness be identified beyond which a patient should not be listed for an LT? How should we deal with patients already listed with less severe disease who are exposed to brutal deterioration of liver function and death due to restricted access to LT? Finally, how to identify and manage patients that are not candidates for LT and who do not recover adequate liver function?įig. In the absence of any prospect of LT, withdrawal of care could be discussed to ensure respect of patient life, dignity and wishes. This window must be identified swiftly after admission given the poor short-term survival of patients with very high MELD scores. The absence of “definitive” contraindications and the control of “dynamic” contraindications allow a “transplantation window” to be defined. Using this expertise, data are accumulating on favourable post-LT outcomes in very high MELD populations, particularly when LT is performed in a situation of stabilization/improvement of organ failures in selected candidates. So far, local expertise remains the last safeguard to LT. Consideration of a patient’s comorbidities and frailty is an appealing predictive approach in this population that has proven of great value in many other diseases. Despite this, the performance of scores based on these variables is still insufficient. Variables associated with poor immediate post-LT outcomes have been identified in large studies. Yet, the increased relative scarcity of graft resource must be considered alongside the increased risk of losing a graft in the initial postoperative period when performing LT in “too sick to transplant” patients. LT is still the only curative treatment in this population. Although the prognosis of severely ill cirrhotic patients has recently improved, transplant-free mortality remains high. Sequential assessment of scores or classification based on organ failures within the first days after admission help to stratify the risk of mortality in this population. Such patients are often admitted in a context of acute-on-chronic liver failure with extrahepatic failures. In the era of the “sickest first” policy, patients with very high model for end-stage liver disease (MELD) scores have been increasingly admitted to the intensive care unit with the expectation that they will receive a liver transplant (LT) in the absence of improvement on supportive therapies.
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