title: Orthotopic liver transplantation in critically ill cirrhotic patients with multi-organ failure: a single-center experience.
abstract: Due to the lack of donor organs for orthotopic liver transplantation (OLT) in Germany, a larger proportion of patients advance to multi-organ failure (MOF) before OLT. Twenty-three patients on the waiting list for OLT were admitted to our intensive care unit (ICU) from January 2007 until September 2009. They consisted of 16 men and 7 women of median (25th-75th percentile) age of 60 years (54-65). Acute Physiology and Chronic Health Evaluation (APACHE II) score upon ICU admission was 26 (19-34); Model of End-Stage Liver Disease (MELD) score was 29 (22-41); Sequential Organ Failure Assessment (SOFA) score was 12 (8-16). The 90-day mortality rate was 39%. A decrease in MELD score during the first 48 hours (-2 [-5-0] vs 2 [-1-4]; P=.019) was associated with survival. Thirteen patients underwent transplantation from the ICU. By the time of the OLT, the MELD scores had deteriorated to 38 (33-39) and SOFA scores to 19 (18-19). All patients were mechanically ventilated and received hemodynamic support with catecholamines. Ten of 13 patients (77%) received renal replacement therapy and/or single pass albumin dialysis. Eight of 13 patients (62%) had a SOFA score of 3 or 4 (organ failure) in each of the respective subscores for the cardiovascular, renal, and respiratory systems at the time of OLT. The 90-day mortality rate after OLT was 38% and the 1-year-mortality rate was 54%. Patients who did not survive 90 days post OLT showed lower MELD scores on admission (33 [18-35] vs 44 [32-46]; P=.045), an increased MELD during the first 48 hours (3 [1-4] vs -2 [-8-1]; P=.002), and a longer ICU stay before OLT (32 [18-37] vs 8 [2-15]; P=.006). In conclusion, OLT may be successful treatment for cirrhotic patients with MOF. Outcomes of MOF in cirrhotic patients may improve after OLT but are generally worse than acceptable. A shorter ICU waiting time seemed to be beneficial.
authors.affiliation: 2nd Medical Department, Klinikum rechts der Isar, Technical University of Munich, Munich, Germany. andreas.umgelter@lrz.tu-muenchen.de
authors.forename: A
authors.initials: A
authors.lastname: Umgelter
authors.forename: K
authors.initials: K
authors.lastname: Lange
authors.forename: A
authors.initials: A
authors.lastname: Kornberg
authors.forename: P
authors.initials: P
authors.lastname: Büchler
authors.forename: H
authors.initials: H
authors.lastname: Friess
authors.forename: R M
authors.initials: RM
authors.lastname: Schmid
mesh_terms: D018806:APACHE; D000368:Aged; D002395:Catecholamines / Q000627:therapeutic use; D016009:Chi-Square Distribution; D016638:Critical Illness; D005260:Female; D005858:Germany; D006801:Humans; D007362:Intensive Care Units; D007902:Length of Stay; D008103:Liver Cirrhosis / Q000150:complications / Q000175:diagnosis / Q000401:mortality / Q000601:surgery*; D016031:Liver Transplantation / Q000009:adverse effects / Q000401:mortality; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D018579:Patient Selection; D017582:Renal Replacement Therapy; D012121:Respiration, Artificial; D012189:Retrospective Studies; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D015996:Survival Rate; D013997:Time Factors; D016896:Treatment Outcome; D014662:Vasoconstrictor Agents / Q000627:therapeutic use; D014850:Waiting Lists
chemical_list: D002395:Catecholamines; D014662:Vasoconstrictor Agents