Management of high-risk recipients in liver transplantation

Abstract

 Liver transplantation is the best treatment for end-stage liver diseases and small unresectable hepatocellular carcinomas. With advances in surgical techniques and better perioperative management, more high-risk candidates are accepted for transplant listing. Nonetheless, preoperative renal failure (e.g. hepatorenal syndrome), high cardiovascular risks, high Model for End-stage Liver Disease score, advanced age and re-transplantation remain as challenging conditions, and hence meticulous measures should be observed in order to achieve good outcomes. Preoperative renal failure, in particular hepatorenal syndrome, is one of the main factors for poor survival after liver transplantation. It may be further aggravated by the long wait, as in Hong Kong deceased-donor livers are scarce. The routine practice of timely living donor liver transplantation at our center could achieve favorable short- and long-term survival even in patients with preoperative hepatorenal syndrome. It is recommended in centers with vast experience in living donor liver transplantation. Similarly, for patients with high or ultrahigh Model for End-stage Liver Disease scores (≥25 and ≥35), diligent peri-transplant management can result in good outcomes even in the setting of living donor liver transplantation. Special attention should be paid in order to avoid sepsis and fluid over-loading in recipients. Furthermore, the time to stop donor evaluation in order to avoid futility needs accumulation of center experience. For patients with pre-existing cardiovascular risks, detailed preoperative assessment of cardiac function is mandatory. Our previous study demonstrated that patients with cirrhosis had biventricular dilatation and impaired biventricular systolic strain. After successful liver transplantation, the dilatation and biventricular strain improved. As there is clear documentation of right ventricular malfunction in patients with cirrhosis, a vigilant surveillance echocardiogram by a dedicated transplant cardiologist must be provided while they are awaiting transplantation, as cardiac conditions might further progress and render them unsuitable for transplantation. In patients with cirrhosis and concomitant aortic valve disease, a fine management algorithm should be sought, as either condition will tilt the balance and make the outcomes unsatisfactory. In highly selected patients, management of the cardiac disease together with a timely transplantation has been a successful model in our center. For patients with graft failure, re-transplantation is always a challenging consideration, not to mention living donor liver transplantation. In this regard, a late re-transplantation (more than 3 months after the first transplantation) is particularly difficult, as all the vascular adhesions leading to massive bleeding and a distorted anatomy will result in inadvertent damage to the surrounding structures, and short vascular anastomoses requiring inter-positional grafts will be a stumbling stone for re-transplantation. Considering the patient age, liver transplantation is generally not advisable for elderly patients with preoperative type-1 hepatorenal syndrome, as the survival outcomes would be significantly worse when compared with younger patients and patients without hepatorenal syndrome. This serves as an important point for counselling intended donors especially in the light of living donor liver transplantation. All in all, high-risk patients requiring liver transplantation should be centralized in high-volume centers with relevant expertise. Clinicians should strive for better management of these high-risk patients in order to improve outcomes.