When Is a Critically Ill Cirrhotic Patient Too Sick to Transplant? Development of Consensus Criteria by a Multidisciplinary Panel of 35 International Experts
Emmanuel Weiss, Fuat H. Saner, Sumeet K. Asrani, Gíanni Biancofiore, Annabel Blasi, Jan Lerut, François Durand, Javier Fernández, James Y. Findlay, Constantino Fondevila, Claire Francoz, Thierry Gustot, Samir Jaber, Constantine Karvellas, Kate Kronish, Wim Laleman, Pierre François Laterre, Éric Levesque, M. Susan Mandell, Mark Mc Phail, Paolo Muiesan, Jody C. Olson, Kim M. Olthoff, Antonio Daniele Pinna, Thomas Reiberger, Koen Reyntjens, Faouzi Saliba, Olivier Scatton, Kenneth J. Simpson, Olivier Soubrane, Ram Subramanian, Frank Tacke, Dana Tomescu, Victor W. Xia, Gebhard Wagener, Cathérine Paugam‐Burtz
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.