Defining the threshold for too sick for transplant

The most difficult, and perhaps, most important decision that a clinician makes for a patient on the liver transplant wait-list is when 'not' to proceed with liver transplant. Although an individual may be suitable for transplant surgery at listing, he/she may become too sick while waiting.

This article reviews four specific conditions that commonly arise on the wait-list that may render a candidate too sick for transplant: advancing age, sarcopenia, acute on chronic liver failure, and nonliver-related medical comorbidities. Each condition, per se, is often not a criterion for delisting; the challenge arises when conditions exist in combination--how does one 'sum' up these conditions to quantify risk? Physical frailty, conceptually, represents the conditions in a candidate that are unlikely to reverse after liver function returns, or will take so long to reverse that the patient will be highly vulnerable to postoperative complications. Pretransplant assessments of physical frailty, which are objective, easily administered, and repeated in the clinical setting, enable us to measure the extent to which these factors, in isolation or combination, will reduce both quantity and quality of life after liver transplant.

In this article, I introduce a framework that incorporates objective pretransplant assessments of physical frailty to facilitate the decision regarding when a patient is too sick for transplant.