Outcomes of critically ill patients denied consideration for liver transplantation

Patients with advanced liver disease (ALD) leading to admission to the ICU are often evaluated for possible orthotopic liver transplantation (OLT). Those deemed ineligible for listing for OLT must be managed by medical therapy. The number of patients not eligible for OLT listing will likely increase given the current organ transplant shortage. We performed a retrospective multivariate analysis of mortality predictors for patients denied listing for OLT. One hundred and eighty-three patients denied OLT listing were evaluated over a 3(1)/(2)-yr period, beginning in 1994. Overall mortality was 56% for those not listed versus 12% for those listed for OLT (p < 0.001). Independent predictors of increased mortality among those not listed were APACHE II score (p = 0.001; OR 1.11), sepsis (p = 0.04; OR 2.41), and the need for mechanical ventilation (p = 0.001; OR 3.71). Gastrointestinal (GI) bleeding was associated with decreased mortality (p = 0.02; OR 0.44). We conclude that critically ill patients with ALD denied OLT listing have substantially higher mortality than those listed for OLT. APACHE II score, sepsis, and the need for mechanical ventilation predict increased mortality in this group. Conversely, GI bleeding predicts decreased mortality; therefore, aggressive resuscitative measures seem merited in these patients.