Critical care aspects of the patient awaiting liver transplantation

The indications for liver transplantation have continued to evolve and now extend beyond elective transplantation for decompensated cirrhosis and emergency liver transplantation for acute liver failure (ALF), to patients who present with acute-on-chronic liver failure (ACLF), including those with severe alcoholic hepatitis. This review focuses on the pretransplant critical care aspects of ALF patients and on recent developments, as the ACLF syndrome was defined and early transplantation for alcohol-related hepatitis has entered practice in some countries.

ACLF severity, graded by the number of failing organs, predicts both waiting list and posttransplant mortality. The UK has introduced a national prioritization tier for selected critically ill patients with ACLF. High-volume plasma exchange improves transplant-free survival in ALF, with ongoing trials in ACLF. Artificial liver support and G-CSF have not shown survival benefit in randomized trials. Continuous renal replacement therapy lowers ammonia and is associated with reduced mortality in ALF. Early transplantation for steroid-nonresponsive severe alcohol-related hepatitis produces survival comparable to standard transplantation and is now delivered through structured programmes in some countries.

Pretransplant critical care focuses on extrahepatic organ support and maintaining transplant candidacy. Prognostic scores identify risk but do not by themselves determine futility, which is dynamic and selection-dependent.