Emmanuel Weiss1,2,3, Fuat Saner4, Sumeet K Asrani5, Gianni Biancofiore6, Annabel Blasi7, Jan Lerut8, François Durand9, Javier Fernandez3,10, James Y Findlay11, Constantino Fondevila12, Claire Francoz9, Thierry Gustot13,14,15, Samir Jaber16, Constantine Karvellas17, Kate Kronish18, Wim Laleman19, Pierre François Laterre20, Eric Levesque21,22, M Susan Mandell23, Mark Mc Phail24, Paolo Muiesan25,26, Jody C Olson27, Kim Olthoff28, Antonio Daniele Pinna29, Thomas Reiberger30, Koen Reyntjens31, Faouzi Saliba32, Olivier Scatton33, Kenneth J Simpson34, Olivier Soubrane35, Ram M Subramanian36, Frank Tacke37, Dana Tomescu38, Victor Xia39, Gebhard Wagener40, Catherine Paugam-Burtz1,2. 1. Department of Anesthesiology and Critical Care, Beaujon hospital, DMU Parabol, AP-HP.Nord, Paris. 2. Inserm UMR_S1149, Inserm et Université de Paris, Paris, France. 3. EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure, EF CLIF, Barcelona, Spain. 4. Department of General-, Visceral- and Transplant Surgery, Medical Center University Duisburg-Essen, Duisburg, Germany. 5. Baylor University Medical Center, Dallas, TX. 6. Transplant Anesthesia and Critical Care, Azienda Ospedaliera Universitaria Pisana, University School of Medicine, Pisa, Italy. 7. Anesthesia Department Hospital Clinic of Barcelona, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS). 8. Institute for Experimental and Clinical Research (IREC), Université Catholique Louvain (UCL), Brussels, Belgium. 9. Department of Hepatology, Beaujon hospital, AP-HP, Nord UMR_S1149, Inserm et Université de Paris, Paris, France. 10. Liver ICU, Hospital Clinic, University of Barcelona, Spain. 11. Department of Anesthesiology and Perioperative Medicine, Mayo Clinic, Rochester, MN. 12. Department of General and Digestive Surgery, Liver Transplant Unit, Hospital Clínic, IDIBAPS, CIBERehd, University of Barcelona, Spain. 13. Liver Transplant Unit, Department of Gastroenterology and Hepato-Pancreatology, C.U.B. Hôpital Erasme, Brussels, Belgium. 14. Laboratory of Experimental Gastroenterology, Université Libre de Bruxelles, Brussels, Belgium. 15. Inserm UMR_S1149, Centre de Recherche sur l'inflammation (CRI), Paris, France and EASL CLIF Consortium, European Foundation for the Study of Chronic Liver Failure; EF CLIF, Barcelona, Spain. 16. Inserm U1046, CNRS UMR 9214, Anaesthesiology and Intensive Care, Anaesthesia and Critical Care Department B, Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier, Centre Hospitalier Universitaire Montpellier, Montpellier, France. 17. Division of Gastroenterology (Liver Unit), Department of Critical Care Medicine, University of Alberta, Edmonton, Canada. 18. Department of Anesthesia and Perioperative Medicine, University of California San Francisco, San Francisco, CA. 19. Department of Gastroenterology and Hepatoloy, Section of Liver and Biliopancreatic diseases, University Hospitals Leuven, Leuven, Belgium. 20. Department of Critical Care Medicine, St. Luc University Hospital, Université Catholique de Louvain (UCL), Brussels, Belgium. 21. Department of Anesthesiology and Critical Care, Assistance Publique-Hôpitaux de Paris, Hôpital Henri Mondor, Créteil, France. 22. EA Dynamyc UPEC, ENVA Faculté de Médecine de Créteil, France. 23. Department of Anesthesiology, University of Colorado Hospital, Aurora, CO. 24. Liver Intensive Therapy Unit, Institute of Liver Studies, Department of Inflammation Biology, Kings College London, London, United Kingdom. 25. The Liver Unit, Queen Elizabeth Hospital Birmingham, University of Birmingham, Birmingham, United Kingdom. 26. Department of Liver Surgery, Birmingham Children's Hospital NHS Foundation Trust, Birmingham, United Kingdom. 27. Department of Internal Medicine, Hepatology and Critical Care Medicine, University of Kansas Medical Center, Kansas City, KS. 28. Penn Transplant Institute, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. 29. Organ Failure and Transplant Division- S.Orsola Hospital-University of Bologna, HPB and Transplant Division - Cleveland Clinic Abu Dhabi. 30. Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria. 31. Department of Anesthesiology, University Medical Center Groningen, University of Groningen, the Netherlands. 32. AP-HP Paul Brousse Hospital, Liver Intensive Care Unit, Hepato-Biliary Center; University Paris-Saclay; INSERM UMR 1193, Villejuif, France. 33. Sorbonne Université, INSERM, CRSA, UMRS938, Département de Chirurgie Digesive, Hépato-Biliaire et Transplantation Hépatique, Hopital Pitié-Salpêtrière, AP-HP, Paris. 34. Division of Health Sciences, Department of Hepatology, University of Edinburgh and Scottish Liver Transplantation Unit, Edinburgh, United Kingdom. 35. Department of Hepatobiliopancreatic Surgery and Liver Transplantation, Beaujon hospital, AP-HP.Nord, Inserm UMR_S1149, Inserm et Université de Paris, Paris, France. 36. Divisions of Critical Care and Hepatology, Emory University School of Medicine, Atlanta, GA. 37. Charité Universitaetsmedizin Berlin, Department of Hepatology and Gastroenterology, Berlin, Germany. 38. Department of Anesthesiology and Intensive Care III, Carol Davila University of Medicine and Pharmacy, Fundeni Clinical Institute, Bucharest, Romania. 39. Department of Anesthesiology and Perioperative Medicine, Ronald Reagan UCLA Medical Center, David Geffen School of Medicine at UCLA, Los Angeles, CA. 40. Department of Anesthesiology, College of Physicians and Surgeons of Columbia University, New York, NY.
Abstract
BACKGROUND: Critically ill cirrhotic patients are increasingly transplanted, but there is no consensus about futile liver transplantation (LT). Therefore, the decision to delay or deny LT is often extensively debated. These debates arise from different opinions of futility among transplant team members. This study aims to achieve a multinational and multidisciplinary consensus on the definition of futility in LT and to develop well-articulated criteria for not proceeding with LT due to futility. METHODS: Thirty-five international experts from anesthesiology/intensive care, hepatology, and transplant surgery were surveyed using the Delphi method. More than 70% of similar answers to a question were necessary to define agreement. RESULTS: The panel recommended patient and graft survival at 1 year after LT to define futility. Severe frailty and persistent fever or <72 hours of appropriate antimicrobial therapy in case of ongoing sepsis were considered reasons to delay LT. A simple assessment of the number of organs failing was considered the most appropriate way to decide whether LT should be delayed or denied, with respiratory, circulatory and metabolic failures having the most influence in this decision. The thresholds of severity of organ failures contraindicating LT for which a consensus was achieved were a Pao2/FiO2 ratio<150 mm Hg, a norepinephrine dose >1 μg/kg per minute and a serum lactate level >9 mmol/L. CONCLUSIONS: Our expert panel provides a consensus on the definition of futile LT and on specific criteria for postponing or denying LT. A framework that may facilitate the decision if a patient is too sick for transplant is presented.
BACKGROUND:Critically ill cirrhoticpatients are increasingly transplanted, but there is no consensus about futile liver transplantation (LT). Therefore, the decision to delay or deny LT is often extensively debated. These debates arise from different opinions of futility among transplant team members. This study aims to achieve a multinational and multidisciplinary consensus on the definition of futility in LT and to develop well-articulated criteria for not proceeding with LT due to futility. METHODS: Thirty-five international experts from anesthesiology/intensive care, hepatology, and transplant surgery were surveyed using the Delphi method. More than 70% of similar answers to a question were necessary to define agreement. RESULTS: The panel recommended patient and graft survival at 1 year after LT to define futility. Severe frailty and persistent fever or <72 hours of appropriate antimicrobial therapy in case of ongoing sepsis were considered reasons to delay LT. A simple assessment of the number of organs failing was considered the most appropriate way to decide whether LT should be delayed or denied, with respiratory, circulatory and metabolic failures having the most influence in this decision. The thresholds of severity of organ failures contraindicating LT for which a consensus was achieved were a Pao2/FiO2 ratio<150 mm Hg, a norepinephrine dose >1 μg/kg per minute and a serum lactate level >9 mmol/L. CONCLUSIONS: Our expert panel provides a consensus on the definition of futile LT and on specific criteria for postponing or denying LT. A framework that may facilitate the decision if a patient is too sick for transplant is presented.
Authors: Vinay Sundaram; Sarvanand Patel; Kirti Shetty; Christina C Lindenmeyer; Robert S Rahimi; Gianina Flocco; Atef Al-Attar; Constantine J Karvellas; Suryanarayana Challa; Harapriya Maddur; Janice H Jou; Michael Kriss; Lance L Stein; Alex H Xiao; Ross H Vyhmeister; Ellen W Green; Braidie Campbell; William Cranford; Nadim Mahmud; Brett E Fortune Journal: Liver Transpl Date: 2022-02-09 Impact factor: 6.112