In France, for instance, the overall number of newly listed patients increased by 24% between 20 with an average 2.4 transplant candidates per available graft. A stagnant pool of donor organs contrasts with an increasing number of candidates. Illustrating the success of the procedure, around 23,000 transplants were performed around the world in 2017. Since the first experiment by Thomas E Starzl in the 1960s, 1 liver transplants (LTs) have revolutionized the treatment of patients with severe liver disease, dramatically improving outcomes. 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.
0 Comments
Leave a Reply. |
Details
AuthorWrite something about yourself. No need to be fancy, just an overview. ArchivesCategories |