Adjuvant drugs for end-stage liver failure and transplantation

End-stage liver failure is currently treatable both by dialysis and by liver transplantation, but this does not detract from its being a complex pathophysiological and pharmacological entity. More patients survive after transplant because of the impressive developments that enabled improved liver preservation, anesthesia and surgical techniques, as well as immunosuppressive drug therapy. Because of its multifaceted metabolism, liver failure can nevertheless cause a complex of pathophysiological conditions and, as such, poses a challenge for surgeons and anesthesiologists alike, not only before surgery but during transplantation as well. Obviating these problems frequently requires the use of adjunct drugs before, during and after liver transplantation, and these medications must be carefully balanced with each other while being alert to the avoidance of negative side effects. Hepatorenal syndrome and massive bleeding are the two main grave phenomena that characterize these patients before and during liver transplant, and this article will provide an overview of the adjunct drugs that are used to circumvent them perioperatively. Specifically, it details the drugs that are used to preserve and improve the already precarious hemodynamic conditions (e.g, by vasopressors, vasodilators, and beta blockers), as well as diuretics and hepato-protective drugs (e.g, furosemide, mannitol), antifibrinolytics (including the new recombinant activated Factor VII) and immunosuppressive drugs. Their doses and the ongoing debate on their concomitant use are reported as well.