Patients Awaiting Liver Transplantation Research Articles

The Recent Trends of Systemic Treatments and Locoregional Therapies for Cholangiocarcinoma.

Cholangiocarcinoma (CCA) is a hepatic malignancy that has a rapidly increasing incidence. CCA is anatomically classified into intrahepatic (iCCA) and extrahepatic (eCCA), which is further divided into perihilar (pCCA) and distal (dCCA) subtypes, with higher incidence rates in Asia. Despite its rarity, CCA has a low 5-year survival rate and remains the leading cause of primary liver tumor-related death over the past 10-20 years. The systemic therapy section discusses gemcitabine-based regimens as primary treatments, along with oxaliplatin-based options. Second-line therapy is limited but may include short-term infusional fluorouracil (FU) plus leucovorin (LV) and oxaliplatin. The adjuvant therapy section discusses approaches to improve overall survival (OS) post-surgery. However, only a minority of CCA patients qualify for surgical resection. In comparison to adjuvant therapies, neoadjuvant therapy for unresectable cases shows promise. Gemcitabine and cisplatin indicate potential benefits for patients awaiting liver transplantation. The addition of immunotherapies to chemotherapy in combination is discussed. Nivolumab and innovative approaches like CAR-T cells, TRBAs, and oncolytic viruses are explored. We aim in this review to provide a comprehensive report on the systemic and locoregional therapies for CCA.

The Recent Trends of Systemic Treatments and Locoregional Therapies for Cholangiocarcinoma

Cholangiocarcinoma (CCA) is a hepatic malignancy that has a rapidly increasing incidence. CCA is anatomically classified into intrahepatic (iCCA) and extrahepatic (eCCA), which is further divided into perihilar (pCCA) and distal (dCCA) subtypes, with higher incidence rates in Asia. Despite its rarity, CCA has a low 5-year survival rate and remains the leading cause of primary liver tumor-related death over the past 10–20 years. The systemic therapy section discusses gemcitabine-based regimens as primary treatments, along with oxaliplatin-based options. Second-line therapy is limited but may include short-term infusional fluorouracil (FU) plus leucovorin (LV) and oxaliplatin. The adjuvant therapy section discusses approaches to improve overall survival (OS) post-surgery. However, only a minority of CCA patients qualify for surgical resection. In comparison to adjuvant therapies, neoadjuvant therapy for unresectable cases shows promise. Gemcitabine and cisplatin indicate potential benefits for patients awaiting liver transplantation. The addition of immunotherapies to chemotherapy in combination is discussed. Nivolumab and innovative approaches like CAR-T cells, TRBAs, and oncolytic viruses are explored. We aim in this review to provide a comprehensive report on the systemic and locoregional therapies for CCA.

Evaluation of Hand Grip Strength Test: As a Reliable, reproducible, Costeffective Tool to Assess the Nutritional Status and Outcomes of Cirrhotic Patients Awaiting Liver Transplant

Abstract Background Malnutrition is common comorbidity in patients with cirrhosis. Its prognostic value is indisputable as it greatly affects the evolution of liver disease. It has a major impact on both morbidity and mortality before and after liver-transplantation. Being now integrated in the definition of malnutrition and recognized as new entity in the international classification of disease, physicians have taken great interest in sarcopenia. Its negative impact on survival of cirrhotic patients is well demonstrated, particularly those on wait-list of liver-transplantation (LT). Aim of the Work The aim of this study is twofold; first, to assess the effect of malnutrition on mortality in patients awaiting Liver transplantation and, second, to evaluate hand grip strength HGS as a reliable, non-invasive, and inexpensive tool that can be used in routine clinical practice for early diagnosis and stratification of severity of malnutrition in patients awaiting Liver transplantation. Patients and Methods This is a prospective observational study, which was conducted at Ain- Shams specialized Hospital, liver transplantation department. The study was conducted after obtaining institutional ethics committee approval. Nutritional status assessment will be made by dominant hand grip strength (HGS) and all patients undergo a detailed nutrition assessment by a qualified Clinical Dietitian and nutritional intervention was recommended based on severity of malnutrition. Disease severity was classified according to the criteria proposed by Child-Pugh and the Model for End stage Liver Disease (CTP and MELD). The scores were noted during liver transplantation evaluation. Results We found in this study that 15 of the 29 included patients (51.7%) were 50-65 years old and 21 were males (72%) and 8 were females (27.6%). Six of the included patients were diagnosed as cryptogenic cirrhosis (21%) while 18 were diagnosed as post0viral cirrhosis (62%). Malnutrition was diagnosed in 25 out of the 29 included patients (86.2%) and only 4 patients were well- nourished (13.9) by SGA. In all included patients HGS was reduced and mean HGS was (21.9 ± 3.85 Kg), reflecting sarcopenia (reduced muscle strength). There was also reduction in MAMC (mean 18.7 ± 4.12 cm) with correlation between MAMC and HGS reflecting reduction in muscle mass and strength. Conclusion Malnutrition as assessed by SGA is very frequent in cirrhotic patients on wait-list for liver transplantation. This malnutrition in negatively affecting survival and should be managed by intensive nutritional intervention to improve post-transplant survival. HGS is reduced in most cirrhotic patients waiting for LT, this can worsen the prognosis independent of other confounders and should be assessed as predicted in all cirrhotic patients. HGS by dynamometer is a simple, cost effective and reasonably reliable to be used as screening tool to diagnose sarcopenia in patients with ESLD and can be followed by more confirmatory methods if needed as CT on Lumber 3 and determination of LMI (Lumber mass index)

Association between protein-energy malnutrition and healthcare use among adult patients after liver transplantation: A retrospective cohort study.

Protein-energy malnutrition is associated with poor surgical outcomes in liver transplant patients, but its impact on healthcare use has not been precisely characterized. We sought to quantify the burden of protein-energy malnutrition in hospitalized patients undergoing liver transplantation. Current Procedural Terminology codes were used to identify United States hospitalizations between 2011 and 2018 for liver transplantation using the Nationwide Inpatient Sample. Patients <18 years old were excluded. Protein-energy malnutrition was identified by International Classification of Diseases Ninth and Tenth Revision codes. Multivariable regression was used to determine associations between protein-energy malnutrition and hospital outcomes, including hospital length of stay and hospital charges/costs. Of 9856 hospitalizations, 2835 (29%) had protein-energy malnutrition. Patients with protein-energy malnutrition had greater comorbidity burden and in-hospital acuity (eg, dialysis, sepsis, vasopressors, or mechanical ventilation). The adjusted median difference of protein-energy malnutrition vs no protein-energy malnutrition for length of stay was 6.4 days (95% CI, 5.6-7.1; P < 0.001), for hospital charges was $108,063 (95% CI, $93,172-$122,953; P < 0.001), and for hospital costs was $23,636 (95% CI, $20,390-$26,882; P < 0.001). Among patients undergoing liver transplantation, protein-energy malnutrition was associated with increased length of stay and hospital charges/costs. The additional cost of protein-energy malnutrition to liver transplantation programs was $23,636 per protein-energy malnutrition hospitalization. Our data justify the development of and investment in personnel and programs dedicated to reversing-or even preventing-protein-energy malnutrition in patients awaiting liver transplantation.

Ayurveda management is effective in preventing development of complications in a patient of chronic hepatic parenchymal disease awaiting liver transplant: a case report

Abstract Background: Chronic liver disease (CLD) always carries the risk of life-threatening complications, with the last treatment resort being liver transplant, which has its challenges. Prevention programs and early management of chronic liver diseases are recognized as new health measures worldwide. Ayurveda being a holistic science not only resolves symptoms but also cures patients at the root level and serves as a safe, cost-effective treatment modality. Aim: To manage chronic hepatic parenchymal disease in patients awaiting liver transplant with Ayurveda treatment. Materials and Methods: In this study, we present a case of a a 35-year-old male patient diagnosed with chronic liver disease with grade 2 esophageal varices and advised for a liver transplant, which has been successfully managed for a duration of past 2.5 years by Ayurveda oral therapy. Results: Improvement in clinical signs and symptoms along with decrease in Child–Pugh Grade Score. Conclusion: Ayurvedic treatment provides a symptom-free life and improved liver function profile while the patient was awaiting liver transplant. It prolongs the duration for liver transplantation.

Reversing malnutrition and low muscle strength with targeted enteral feeding in patients awaiting liver transplant: A randomized controlled trial.

Most patients with decompensated cirrhosis fail to meet their nutrition targets. The impact of nasogastric feeding (NGF) on malnutrition in cirrhosis remains unknown. This study aims to assess the impact of pre-transplant NGF on pre- and post-liver transplant outcomes. This single-centre, prospective randomized controlled trial of 55 patients with severe malnutrition and low handgrip strength (HGS) compared standard high-energy high-protein diet to diet plus supplemental nocturnal NGF whilst awaiting transplant. The primary outcome was change in HGS. Median age was 58.5 years (IQR 51.1-64), median MELD 24 (20-28.5), and 32 (58%) were male. Median duration of NGF was 63.0 days (34.5-127), following which time the median between group difference in HGS was 3.6kg (95% CI: 1.7-5.2, p<0.001); an increase of 20% from baseline. Mid upper-arm circumference, triceps skinfold and immune function all increased significantly with NGF. Muscle and nutritional parameters continued to improve with increasing duration of feeding. NGF significantly increased daily energy intake between groups by 1285kcal (95% CI: 860-1677) and protein intake by 51g (95% CI: 32-71) (both p<0.001). All NGF patients met >100% of their measured nutritional requirements. Post-transplant clinical outcomes were similar between groups. Targeted enteral feeding before LT improves HGS, anthropometry and immune function in severely malnourished cirrhotic patients. These findings provide a strong rationale for early consideration of NGF to reverse malnutrition and improve muscle strength. Appropriately powered studies should explore whether NGF can also impact clinically relevant outcomes including pre- and post-transplant mortality.

Sarcopenia in cirrhotic patients: Does frailty matter while waiting for a liver transplant?

Sarcopenia reflects patient frailty and should be routinely assessed due to its high prevalence in cirrhotic patients awaiting liver transplants. Pre-transplant nutritional optimization should be tailored for patients with a definitive diagnosis of sarcopenia, therefore improving functional status at transplant and reducing post-transplant mortality. Hepatologists and transplant surgeons should have raised awareness regarding sarcopenia and the reflected frailty that hinder posttransplant outcomes. The policymakers should also take into account when modifying the organ allocation model that sarcopenia or frailty might become a decisive factor in allocating organs for cirrhotic patients, in order to ensure post-transplant survival and quality of life.

Place of tyrosine kinase inhibitors in the first line of treatment of hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) in Russia and worldwide is steadily increasing over time. The majority of HCC patients are diagnosed at a late stage of the disease, which is not suitable for potentially curative treatment methods. Before the emergence of new treatment regimens, the median overall survival for this condition was just over one year. Studying combinations of immunotherapy and targeted therapy has improved clinical outcomes compared to monotherapy with tyrosine kinase inhibitors, but the new treatment regimens cannot be prescribed to all patients with advanced HCC. The combination of atezolizumab with bevacizumab may be prescribed to eligible patients with advanced hepatocellular carcinoma who do not have varicose veins and have no history of hypertensive crises. In real clinical practice, it is extremely difficult to select patients who meet the inclusion criteria for clinical trials. Monotherapy with tyrosine kinase inhibitors is also effective regardless of the etiology of HCC development and can be prescribed to patients with signs of liver insufficiency (Child-Pugh B) as opposed to combined therapy. Double immunotherapy has shown its efficacy in second-line treatment, and in the future, these combinations may also demonstrate their effectiveness in first-line treatment of hepatocellular carcinoma. There is insufficient evidence on the effectiveness of immunotherapy in patients awaiting liver transplantation. For this category of patients, the drugs of choice are lenvatinib and sorafenib. The article highlights the specific considerations in choosing the treatment regimen based on the etiology of the disease, treatment goals, concomitant patient conditions, and the presence/severity of liver insufficiency.

Clinical course of ascitic syndrome and acute kidney injury in the setting of nonselective beta‑blockers or endoscopic variceal ligation for primary prevention of bleeding in cirrhotic patients awaiting liver transplantation

Objective: to compare the effects of nonselective beta-blockers (NSBB) and endoscopic variceal ligation (EVL) on patient survival, ascites dynamics, and development of acute kidney injury (AKI) during primary prevention of bleeding from the esophageal varices and cardia in patients with decompensated cirrhosis on the liver transplant waiting list (LTWL). Materials and methods. A retrospective comparative study of the clinical data of patients with severe ascites and esophageal varices without a bleeding history at the time of their inclusion in the LTWL was performed. Group 1 patients (n = 84) were prescribed NSBB, alpha and beta-adrenoblockers in order to prevent bleeding and reduce progression of decompensated cirrhosis. Group 2 patients underwent EVL. Results. Demographic, laboratory and instrumental parameters of patients in the compared groups had no significant differences. In both groups, there were no significant differences between the indicators of severity of liver lesions (MELD-Na, Child–Turcotte–Pugh), frequency of severe ascites, frequency of varicose nodes grades 2–3. At follow-up, bleeding developed in 22 patients (13.25%) – 13 patients in the NSBB group and 9 patients in the EVL group (15.47% and 10.97%, respectively, p &gt; 0.05). Patient survival was significantly higher in the EVL group than in the NSBB group. Incidence of refractory ascites, number of patients with grade 3 ascites, and AKI stages 2–3 in the NSBB group, were significantly higher (p &lt; 0.05) than in the EVL group. MELD-Na was the independent predictor of mortality in the EVL group, while low mean arterial pressure (mAP) and presence of AKI were those for patients receiving NSBB. Conclusion. NSBB and EVL are effective methods of primary prevention of bleeding. Mortality rate, number of patients with refractory ascites and severe ascites, and number of patients with AKI stages 2–3 were higher in the NSBB group than in the EVL cohort. In EVL patients, the independent predictor of death was MELD-Na, while in NSBB patients, the independent predictors of mortality were low mAP and presence of AKI.

Impact of Psoas Muscle Wasting Among Cirrhotic Patients Awaiting Liver Transplantation: Predictor of Mortality and Transplant Selection

Impact of Psoas Muscle Wasting Among Cirrhotic Patients Awaiting Liver Transplantation: Predictor of Mortality and Transplant Selection

Addition of Kidney Dysfunction Type to MELD-Na for the Prediction of Survival in Cirrhotic Patients Awaiting Liver Transplantation in Comparison with MELD 3.0 with Albumin.

It is well known that renal dysfunction has a devastating effect on the prognosis of liver cirrhosis. In this study, the aim was to assess whether the incorporation of the kidney dysfunction type into the MELD-Na score enhances its predictive capacity for outcomes in patients awaiting liver transplantation (LT), compared to utilizing the MELD 3.0 score with albumin. In total, 2080 patients awaiting the LT were enrolled at two tertiary care institutions in Korea. Discrimination abilities were analyzed by using Harrell's c-index and iAUC values between MELD-Na-kidney dysfunction type (MELD-Na-KT) and MELD 3.0 with albumin. Clinical endpoints encompassed 3-month survival, 3-month transplant-free survival (TFS), overall survival (OS), and total TFS. Out of the total of 2080 individuals, 669 (32.16%) were male. Regarding the types of renal function impairment, 1614 (77.6%) were in the normal group, 112 (5.38%) in the AKD group, 320 (15.35%) in the CKD group, and 34 (1.63%) were in the AKD on CKD group. MELD 3.0 with albumin showed better discrimination (c-index = 0.714) compared to MELD-Na-KT (c-index = 0.708) in predicting 3-month survival. Similar results were observed for OS, 3-month TFS, and total TFS as well. When divided by sex, MELD 3.0 with albumin showed the comparable prediction of 3-month survival to MELD-Na-KT (c-index 0.675 vs. 0.671, p-value 0.221) in males. However, in the female group, MELD 3.0 with albumin demonstrated better results compared to MELD-Na-KT (c-index 0.733 vs. 0.723, p-value 0.001). The integration of kidney dysfunction types into the MELD-Na did not yield superior prognostic results compared to the MELD 3.0 score with albumin. Rather, in the female group, the MELD 3.0 score with albumin was better able to predict survival. These findings suggest that laboratory values pertaining to liver dysfunction or creatinine levels may be more significant than the type of kidney dysfunction when predicting the short-term prognosis of LT candidates.

Nonselective beta-blockers may lead to stage 2 acute kidney injury and waitlist mortality in child class C cirrhosis.

Nonselective beta-blockers (NSBB) protect patients with compensated cirrhosis; however, it is unclear if NSBB is associated with acute kidney injury (AKI) in patients with decompensated cirrhosis. We aimed to determine if the use of NSBB was associated with an increased risk of stage II AKI or greater and waitlist mortality (WLM) among patients with decompensated cirrhosis awaiting liver transplant stratified by cirrhosis severity. Included were 1816 outpatients listed for liver transplantation at UCSF from June 2012 to April 2022. Our primary outcome was stage 2 AKI (>200% increase in serum creatinine). Our secondary outcome was WLM (all-cause mortality). Our primary exposure was the use of any NSBB derived using natural language processing of clinical notes. Multivariable Cox proportional hazards models with time-dependent variables were used to determine the HR of NSBB use on stage 2 AKI and WLM, stratified by Child-Pugh Score. The average age of the cohort was 58 years old, with 35% identifying as female. In multivariable time-dependent models, NSBB use was associated with 1.53 × (95 CI 1.19-1.97) the hazard of stage 2 AKI in the cohort overall and 1.80 × (95 CI 1.26-2.57) among those with Child C cirrhosis, respectively. Similarly, NSBB use was associated with 1.30 × (95 CI 1.07-1.59) and 1.45 × (95 CI 1.03-2.03) the hazard of WLM, overall and in Child C, respectively. NSBB use was not significantly associated with AKI nor WLM among those with Child A. NSBB use is associated with Stage 2 AKI and WLM in patients awaiting liver transplantation and Child C cirrhosis. These data suggest cautious use of NSBBs in patients in this population.

MELD 3.0 in Advanced Chronic Liver Disease.

The MELD (model for end-stage liver disease) 3.0 score was developed to replace the MELD-Na score that is currently used to prioritize liver allocation for cirrhotic patients awaiting liver transplantation in the United States. The MELD 3.0 calculator includes new inputs from patient sex and serum albumin levels and has new weights for serum sodium, bilirubin, international normalized ratio, and creatinine levels. It is expected that use of MELD 3.0 scores will reduce overall waitlist mortality modestly and improve access for female liver transplant candidates. The utility of MELD 3.0 and PELDcre (pediatric end-stage liver disease, creatinine) scores for risk stratification in cirrhotic patients undergoing major abdominal surgery, placement of a transjugular intrahepatic portosystemic shunt, and other interventions requires further study. This article reviews the background of the MELD score and the rationale to create MELD 3.0 as well as potential implications of using this newer risk stratification tool in clinical practice.

Preexisting portal vein thrombosis and adult LDLT: A retrospective cohort analysis

BackgroundPortal Vein Thrombosis (PVT) is a common concern in cirrhotic patients awaiting liver transplantation (LT), with high morbidity and mortality rates. While preexisting PVT was traditionally considered a contraindication for the LT procedure, recent advances in surgical techniques have provided new possibilities for operating on these patients. This retrospective cohort study compared the surgical outcomes of adult living donor liver transplantation (LDLT) patients with and without preexisting PVT. MethodsThe study analyzed data from 416 liver transplant recipients and included 270 patients without PVT and 69 patients with PVT who underwent LDLT between March 2019 and March 2023. Preoperative imaging methods and intraoperative assessments were used to diagnose PVT and classify the extent of the thrombus using the Yerdel classification. Various surgical techniques were employed to remove the thrombus and establish a portal flow to the graft. Postoperatively, patients were monitored for complications and followed up regularly. ResultsThere were no significant differences between the non-PVT and PVT groups regarding recipient age, gender, body mass index, primary disease leading to transplantation, Child-Pugh class, or Model for End-Stage Liver Disease (MELD) score. The operative variables, including graft type, duration of surgery, and cold and warm ischemia times, were also similar between the groups. The surgical procedures varied based on the Yerdel classification grade of PVT, with most patients undergoing partial or complete thrombectomy. The mean hospital stays, intensive care unit (ICU) stay duration, and reexploration rates were comparable between the non-PVT and PVT groups. However, the incidence of portal vein thrombosis was significantly higher in the PVT group (p < 0.001). Other complications, such as portal vein stenosis and hepatic artery thrombosis, occurred in a small number of patients. ConclusionThis retrospective cohort analysis demonstrates the feasibility of performing LDLT in patients with preexisting PVT using various surgical techniques. While the overall surgical outcomes and postoperative complications were comparable between patients with and without PVT, the incidence of portal vein thrombosis was higher in the PVT group. Further studies are needed to explore optimal management strategies for PVT in LDLT patients and improve outcomes in this population.

Sarcopenia and sarcopenic obesity in patients awaiting liver transplantation

Sarcopenia and sarcopenic obesity in patients awaiting liver transplantation

Results of transarterial chemoembolization of hepatocellular carcinoma as a bridging therapy to liver transplantation.

To evaluate the degree of tumor necrosis after transarterial chemoembolization (TACE), used as a bridging therapy in patients awaiting liver transplantation, and its effect on survival. This was a retrospective cohort study involving 118 patients submitted to TACE prior to liver transplantation, after which the degree of tumor necrosis in the explant and post-transplant survival were evaluated. Total necrosis of the neoplastic nodule in the explant was observed in 76 patients (64.4%). Of the patients with total necrosis in the explanted liver, 77.8% had presented a complete response on imaging examinations. Drug-eluting bead TACE (DEB-TACE), despite showing a lower rate of complications than conventional TACE, provided a lower degree of total necrosis, although there was no statistical difference between the two. By the end of the study period, 26 of the patients had died. Survival was longer among the patients with total necrosis than among those with partial or no necrosis (HR = 2.24 [95% CI: 0.91-5.53]; p = 0.078). In patients undergoing TACE as a bridging therapy, total tumor necrosis appears to be associated with improved patient survival.

Different serum sodium assay, different model for end stage liver disease - sodium scores in patients awaiting liver transplant: A cross-sectional study.

Sodium can be measured with direct or indirect methods; abnormal plasma total protein concentration can impact on sodium measured by indirect ion-selective electrodes (ISE). Serum sodium is an important item to determine the Model for End Stage Liver Disease Sodium (MELD-Na) score, commonly used for liver graft allocation. Patients with cirrhosis usually have hypoproteinemia. The aim of this study was to determine if there was a significant difference between the MELD-Na scores calculated based on the results of two different serum sodium ISE: indirect and direct. This was a retrospective study; we included 166 patients that underwent liver transplant assessment, and that had paired (i.e. same date and time) direct and indirect sodium determinations. We calculated the MELD-Na scores with both sodium determinations, and we compared them. There was a significant difference between MELD-Na scores; the mean difference was 0.4±1.3. If MELD-Na score had been determined by the sodium measured by the direct ISE, 69 patients (42%) would have stayed in the same place on the waiting list, 67 patients (40%) would have moved up, and 30 patients (18%) would have moved down. There was a statistically significant difference between the MELD-Na scores calculated based on the two different sodium concentrations, which would theoretically result in changes in the order of the waiting list. This finding should prompt studies to assess if MELD-Na calculated based on direct methods has a better performance to predict clinically relevant outcomes.

The number of hepatocellular carcinoma foci as predictor of poor response to tumor-directed therapies in patients awaiting liver transplantation: a prospective cohort study.

Tumor-directed therapies (TDTs) are a constitutive part of hepatocellular carcinoma (HCC) treatment in patients awaiting liver transplantation (LT). While most patients benefit from TDTs as a bridge to LT, some patients drop out from the waiting list due to tumor progression. The study aimed to determine the risk factors for poor treatment outcome following TDTs among patients with HCC awaiting LT. A total of 123 patients with HCC were evaluated with 92 patients meeting Milan Criteria enrolled in the prospective cohort study. Tumor response was evaluated using the modified Response Evaluation Criteria for Solid Tumors for HCC 1 month after the procedure. The risk factors for progressive disease (PD) and dropout were evaluated. After TDT, 55 patients (59.8%) achieved complete or partial response (44.6% and 15.2% respectively), 17 patients (18.5%) had stable disease, and 20 patients (21.7%) were assessed as PD. Multivariate analysis revealed a significant and independent association between the number of HCC foci and PD ( P = 0.03, OR = 2.68). There was no statistically significant association between treatment response and demographics, MELDNa score, pre-and post-treatment alpha-fetoprotein (AFP), cumulative tumor burden the largest tumor size, or TDT modality. PD was the major cause of dropout in our cohort. Pre-treatment AFP levels ≥200 ng/ml had a strong association with dropout after TDTs ( P = 0.0005). This study demonstrated the presence of multifocal HCC is the sole prognostic factor for PD following TDTs in HCC patients awaiting LT. We recommend prioritizing patients with multifocal HCC within Milan criteria by exception points for LT to improve the dropout rate.

Management of the acute on chronic liver failure in the intensive care unit.

Acute on chronic liver failure (ACLF) reflects the development of organ failure(s) in a patient with cirrhosis and is associated with high short-term mortality. Given that ACLF has many different 'phenotypes', medical management needs to take into account the relationship between precipitating insult, organ systems involved and underlying physiology of chronic liver disease/cirrhosis. The goals of intensive care management of patients suffering ACLF are to rapidly recognize and treat inciting events (e.g. infection, severe alcoholic hepatitis and bleeding) and to aggressively support failing organ systems to ensure that patients may successfully undergo liver transplantation or recovery. Management of these patients is complex since they are prone to develop new organ failures and infectious or bleeding complications. ICU therapy parallels that applied in the general ICU population in some complications but differs in others. Given that liver transplantation in ACLF is an emerging and evolving field, multidisciplinary teams with expertise in critical care and transplant medicine best accomplish management of the critically ill ACLF patient. The focus of this review is to identify the common complications of ACLF and to describe the proper management in critically ill patients awaiting liver transplantation in our centres, including organ support, prognostic assessment and how to assess when recovery is unlikely.

Obesity management for the pre–liver transplant and post–liver transplant patient

Obesity management for the pre–liver transplant and post–liver transplant patient