Transplantation for the Very Sick Patient—Donor and Recipient Factors

Abstract

Patients with end-stage chronic liver disease (CLD) frequently deteriorate with development of a ‘frail’ state and progress to development of extra-hepatic organ failures. Making the clinical judgement when a patient is ‘too sick’ to proceed with liver transplantation is challenging; we summarise recent studies that may inform decision-making. Reports quantify the impact of both recipient and donor factors related to early post-transplant survival, with consistent adverse association of advanced donor and recipient age, under-nutrition, sarcopenia and impaired functional status, and requirement for critical care unit admission and organ support. Survival for ‘very sick’ recipients has shown progressive improvement over time, but evidence is increasing of much greater post-transplant resource use and cost. Factors associated with adverse outcomes in very sick recipients are becoming more clearly delineated. The increasing success of transplantation and exploration of its extended use must be tempered by the recognition of the consequences upon constrained clinical resources.