title: Liver transplantation in patients with end-stage liver disease requiring intensive care unit admission and intubation.
abstract: Data regarding transplantation outcomes in ventilated intensive care unit (ICU)-dependent patients with end-stage liver disease (ESLD) are conflicting. This single-center cohort study investigated the outcomes of patients with ESLD who were intubated with mechanical support before liver transplantation (LT). The ICU plus intubation group consisted of 42 patients with decompensated cirrhosis and mechanical ventilation before transplantation. LT was considered for intubated ICU patients if the fraction of inspired oxygen was ≤40% with a positive end-expiratory pressure ≤ 10, low pressor requirements, and the absence of an active infection. Intubated ICU patients were compared to 80 patients requiring ICU admission before transplantation without intubation and to 126 matched non-ICU-bound patients. Patients requiring ICU care with intubation and ICU care alone had more severe postoperative complications than non-ICU-bound patients. Intubation before transplantation was associated with more postoperative pneumonias (15% in intubated ICU transplant candidates, 5% in ICU-bound but not intubated patients, and 3% in control group patients; P = 0.02). Parameters of reperfusion injury and renal function on postoperative day (POD) 2 and POD 7 were similar in all groups. Bilirubin levels were higher in the ICU plus intubation group at POD 2 and POD 7 after transplantation but were normalized in all groups within 3 months. The ICU plus intubation group versus the ICU-only group and the non-ICU group had decreased 1-, 3-, and 5-year graft survival (81% versus 84% versus 92%, 76% versus 78% versus 87%, and 71% versus 77% versus 84%, respectively; P = 0.19), but statistical significance was not reached. A Glasgow coma scale score of <7 versus >7 before transplantation was associated with high postoperative mortality in ICU-bound patients requiring intubation (38% versus 23%; P = 0.01). In conclusion, ICU admission and mechanical ventilation should not be considered contraindications for LT. With careful patient selection, acceptable long-term outcomes can be achieved despite increased postoperative complications.
authors: Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Canada.
authors: Jan
authors: J
authors: Knaak
authors: Critical Care Medicine, Toronto General Hospital, Toronto, Canada.
authors: Mark
authors: M
authors: McVey
authors: Department of Medicine, University of Minnesota. Minneapolis, Minneapolis, MN.
authors: Fateh
authors: F
authors: Bazerbachi
authors: Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Canada.
authors: Nicolás
authors: N
authors: Goldaracena
authors: Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Canada.
authors: Vinzent
authors: V
authors: Spetzler
authors: Multiorgan transplant program, Department of Medicine, Toronto General Hospital, Toronto, Canada.
authors: Nazia
authors: N
authors: Selzner
authors: Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Canada.
authors: Mark
authors: M
authors: Cattral
authors: Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Canada.
authors: Paul
authors: P
authors: Greig
authors: Multiorgan transplant program, Department of Medicine, Toronto General Hospital, Toronto, Canada.
authors: Les
authors: L
authors: Lilly
authors: Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Canada.
authors: Ian
authors: I
authors: McGilvray
authors: Multiorgan transplant program, Department of Medicine, Toronto General Hospital, Toronto, Canada.
authors: Gary
authors: G
authors: Levy
authors: Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Canada.
authors: Anand
authors: A
authors: Ghanekar
authors: Multiorgan transplant program, Department of Medicine, Toronto General Hospital, Toronto, Canada.
authors: Eberhard
authors: E
authors: Renner
authors: Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Canada.
authors: David
authors: D
authors: Grant
authors: Critical Care Medicine, Toronto General Hospital, Toronto, Canada.
authors: Laura
authors: L
authors: Hawryluck
authors: Multi-Organ Transplant Program, Department of Surgery, Toronto General Hospital, Toronto, Canada.
authors: Markus
authors: M
authors: Selzner
mesh_terms: D000328:Adult; D058625:End Stage Liver Disease / Q000601:surgery*; D006801:Humans; D007362:Intensive Care Units; D007442:Intubation, Intratracheal; D016031:Liver Transplantation / Q000401:mortality*; D008875:Middle Aged; D009864:Ontario / Q000453:epidemiology; D012307:Risk Factors