The document discusses liver transplantation for critically ill patients. It provides an agenda on the topic and discusses evidence that transplantation can provide a survival benefit for these patients. It examines different scores used to measure illness severity and transplant futility, such as MELD, CLIF-C ACLF, and organ failure scores. Contraindications for transplantation like number of organ failures, infections, and poor functional status are presented. Timing of transplantation is also important, with a window of opportunity for patients with evolving ACLF. Management of coagulopathy, fluids, and circulation in critically ill transplant candidates is covered. The conclusion is that transplantation can improve survival for ACLF patients when done promptly based on illness scores and the patient's clinical condition

1. The Critically Ill
Transplant Candidate
Prof. Amany Sholkamy
(2)MSc., MD
Cairo University

2. Agenda:
• Evidence of transplant benefit.
• How to measure futility of Tx.
• Timing for Tx
• Contraindications to Tx.
• Management.
• Unanswered questions.

3. Survival according to
hospitalization
status at the time of
Tx.
Artzner et al 2021

4. Who Is The
Critically Ill
Potential Recipient?
A patient from the ICU?
A patient with higher MELD?
A patient with certain type(s) or number
of OF?

5. Patient identification:
Rapid and prompt
identification is of
utmost importance.
Critically ill Tx
candidate is either ALF
or ACLF patients, both
will reside in an
ITU/(ICU).

6. MELD score
• It is the current prognostic model
accepted worldwide.
• MELD scores (MELD, MELD-Na,
MELD 3) are the universal score of
assessing Tx futility/survival.
• However, MELD do not perform
well in the critically ill.

7. CLIF-C ACLF score versus other scores

8. EASL 2021

10. CLIF-C ACLF/AD score
(Chronic Liver Failure-
Consortium score)

11. CLIF-organ failure score and ACLF grades

12. What is the chance
of post Tx survival
of ACLF patients?
Is it worth .. !???
Specially in LDLT

13. Liver Tx in the most critically ill, Multicenter study in ACLF -3 patients
Studies demonstrate that post Tx survival is better than without Tx. Results are better than
older studies before 2010; may be because of improved surgical techniques, better recipient
preoperative preparation and postoperative care. Adding to all; the better understanding of the
nature of the ACLF.

14. Reports of patient survival after liver Tx for ACLF
Jalan et al 2021
LDLT

15. Conditions
making Tx futile
Contraindications

16. Predictors of death before TX
Artzner et al 2021

17. Contraindications:
I) Higher number and type of OFs.
Pro
• Mortality goes higher
with increasing number
of OFs.
• How many OF should
make Tx futile.?
Con
• Price to pay is minor with
just a 9% reduction in 1y
survival after Tx in
patients with 5-6 Ofs
compared to those with
less OFs.
Not only number;
the type of OF
also count.

18. Three organ failures are of major
importance in the decision to TX:
Respiratory
Circulatory
Metabolic

19. Artzner et al 2020

20. Contraindications:
II) Poor functional status
Severe frailty (clinical frailty score >6).
Sarcopenia
Older age.

21. Contraindications:
III) Infections
• Persistent fever >39ºC
• Leukopenia <0.5 g/L
• Infection by MDR bacteria or
invasive fungal infections.
• Less than 72h of antibiotic ttt (by
C&S)
Ongoing
infection
identified
by
any of the
following:

22. Timing for decision & Tx

23. Timing of transplantation
The “Window Opportunity”
Studies revealed that; it is not
the initial ACLF grade that
matters;
but rather
the evolution of the clinical course
of ACLF over time (2-7d).

24. This dynamic process and rapid
patient evolution makes DDLT more
practical and logic than LDLT
LDLT vs DDLT

25. Management
Dynamic process

26. Coagulopathy
• ACLF patients differ than cCLD in that they tend to be more
on the hypocoagulable side.
• INR should not be relied on anymore.
• Trends are now in the direction of using VET in diagnosis
and follow up of Tx candidates pre/intra-operative.

27. Fluids
Balanced crystalloids are
the most beneficial and
acceptable type of fluid.
Be conservative

28. Circulation
Keep BP around 60-65mmHg
Noradrenaline is the mostly
used vasopressor.
Terlipressin and Vasopressin Are
still elegant and acceptable
perioperative Vasopressors.

29. Liver support systems
• Those are considered as bridging therapies.
• They may improve hemodynamics, decrease brain edema but they don’t affect
survival.
• Many systems have been designed:
MARS/Prometheus
Plasmapheresis
DIALIVE
Cost
&
availability

30. How do they work?

31. Other bridging options
• Auxiliary partial LT.
• G-CSF:
Potential treatment effectiveness may be related to the improvement of neutrophil
function.
• Cell Tx and regenerative medicine:
Hepatocyte/stem cell may act as bridging therapy or may have an anti-inflammatory
effect.

32. Unanswered
questions
??????

33. Future Needs
Scores: Which one is more relevant or accurate. Which
of which???
Intention to treat or “intention to transplant”
Defining acceptable criteria of donors for critically ill
potential recipient.
Registries even for the non transplanted patients.

34. Highlights
Wrap up

35. Conclusion
• Liver Tx for critically ill patients can improve survival.
• One year survival for ACLF -3 pts is up to 81% in several
series.
• Prompt identification, referral and screening for Tx is
important.
• CLIF-C ACLF/AD scores should be used in conjunction with
MELD score.
• The evolution of the patient clinical condition and timing to
Tx is crucial.
• The decision is done by a multidisciplinary team.

36. Thank You