Are liver transplant centres critical for the critically ill patient with cirrhosis?
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Chronic liver disease
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Liver disease
Approximately 11% of all liver transplants performed in Europe are for acute liver failure, with one-year patient survival rates ranging between 50% and 75%. This review summarizes the selection, perioperative management, and outcome of patients transplanted for acute liver failure, with particular reference to the experience at the Hopital Paul Brousse in Paris and at King's College Hospital, London. In both centers, the decision to proceed to liver transplantation is based on criteria that predict a survival of less than 20% with medical management alone. Infectious complications and cerebral edema remain the most common causes of death, and highlight the importance of intensive monitoring and early treatment of perioperative complications. In selected patients, auxiliary partial orthotopic liver transplantation may be a therapeutic option, with the potential for native liver generation and eventual immunosuppression withdrawal in approximately two-thirds of patients.
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Hepatopulmonary syndrome (HPS) is associated with increased waitlist mortality in liver transplantation (LT) candidates. Children with HPS are granted Model for End-Stage Liver Disease (MELD)/Pediatric End-Stage Liver Disease (PELD) exception points for waitlist prioritization in the United States based on criterion developed for adults. In this study, the impact of this MELD/PELD exception policy on post-LT survival in children was examined. A retrospective cohort of patients aged younger than 18 years with a MELD/PELD exception request who underwent LT between 2007 and 2018 were identified in the Scientific Registry of Transplant Recipients. Patients were stratified by waitlist partial pressure of arterial oxygen (PaO 2 ) to assess risk factors for waitlist mortality and post-LT survival. Among 3082 pediatric LT recipients included in the study, 124 patients (4%) received MELD/PELD exception points for HPS. Patients with HPS were a median age of 9 years (interquartile range: 6, 12 years), 54.8% were girls, and 54% were White. Most patients (87.9%) were listed with laboratory MELD/PELD scores <15. Waitlist mortality for patients with HPS exception points was rare and not different from patients without HPS. When stratified by pre-LT PaO 2 , hypoxemia severity was not associated with differences in 1-, 3-, or 5-year survival rates after LT ( p = 0.13). However, patients with HPS showed a slightly lower survival rate at 5 years compared with patients without HPS (88.7% vs. 93.4%; p = 0.04). MELD/PELD exceptions for children with HPS mitigated waitlist mortality, and recipients with HPS experienced excellent 5-year survival after LT, although slightly lower than in patients without HPS. Unlike adults with HPS, the severity of pre-LT hypoxemia in children does not impact post-LT survival. These data suggest that adult criteria for granting MELD/PELD exception points may not appropriately capture HPS severity in pediatric patients. Further prospective multicenter studies to examine the risk factors predicting negative survival outcomes in children with HPS are warranted.
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Abstract: Liver transplantation is challenged by organ shortage and prolonged waiting list time. The goal of the ideal organ allocation system is to transplant individuals least likely to survive without a liver transplantation, and maintain appropriate rates of postoperative survival. Currently, liver allocation in the United States is based on the model for end‐stage liver disease (MELD). Studies have shown MELD to be objective and accurate in predicting short‐term survival in patients with cirrhosis.
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Liver disease
Chronic liver disease
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As the mean Model for End-Stage Liver Disease (MELD) score at time of liver transplantation continues to increase, it is crucial to implement preemptive strategies to reduce wait-list mortality. We review the most common complications that arise in patients with a high MELD score in an effort to highlight strategies that can maximize survival and successful transplantation.
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Waiting list
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Liver disease
Chronic liver disease
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Liver disease
Chronic liver disease
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The model for end-stage liver disease (MELD) is considered to be a good predictor of disease status in patients with end-stage liver disease and has been used for organ distribution in liver transplantation. This article briefly describes the relationship between MELD, MELD-Na score and the mortality of patients waiting for liver transplantation, the intraoperative blood transfusion, the survival, complications, and re-transplantation after liver transplantation.
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End stage liver disease; Liver transplantation; MELD-Na score; Postoperative complications
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Liver disease
Chronic liver disease
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Background data: Liver transplantation is the best therapeutic option for patients with end- stage liver disease due to its excellent long term survival results. The demand for deceased donor liver transplantation vastly exceeds the supply. In the U.S. the Model for End Stage Liver Disease (MELD) score is now used for allocation in liver transplantation waiting lists, replacing the Child- Turcotte- Pugh (CTP) score. The MELD system is based on the risk of death without transplantation and was originally developed for survival estimation in patients after TIPS. The majority of the European countries still use the CTP score for liver organ allocation. However, there is a debate whether the MELD score is superior CTP to predict mortality in patients with cirrhosis on waiting list and after liver transplantation.
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