Potentially inappropriate liver transplantation in the era of the sickest first'' policy - A search for the upper limits

JOURNAL OF HEPATOLOGY

卷:68

Review

Linecker, Michael^1,2  Krones, Tanja^3,4  Berg, Thomas⁵  Niemann, Claus U.^6,7  Steadman, Randolph H.⁸  Dutkowski, Philipp^1,2  Clavien, Pierre-Alain^1,2  Busuttil, Ronald W.⁹  Truog, Robert D.^10,11  Petrowsky, Henrik^1,2 

[1] Univ Hosp Zurich, Swiss HPB & Transplantat Ctr, Zurich, Switzerland

[2] Univ Hosp Zurich, Dept Surg & Transplantat, Zurich, Switzerland

[3] Univ Hosp Zurich, Div Clin Eth, Zurich, Switzerland

[4] Univ Zurich, Inst Biomed Eth & Hist Med, Zurich, Switzerland

[5] Univ Leipzig, Div Hepatol, Leipzig, Germany

[6] Univ Calif San Francisco, Dept Anesthesiol, San Francisco, CA 94143 USA

[7] Univ Calif San Francisco, Dept Surg, San Francisco, CA USA

[8] Univ Calif Los Angeles, Ronald Reagan Med Ctr, Dept Anesthesiol & Perioperat Med, Los Angeles, CA USA

[9] Univ Calif Los Angeles, Ronald Reagan Med Ctr, Dumont UCLA Transplant Ctr, Los Angeles, CA USA

[10] Harvard Med Sch, Ctr Bioeth, Boston, MA USA

[11] Boston Childrens Hosp, Dept Anesthesia Perioperat & Pain Med, Boston, MA USA

关键词: Liver transplant;    Equity;    Efficiency;    Futile;    Organ shortage;    ALF;    CLF;    ACLF;   

DOI  :  10.1016/j.jhep.2017.11.008

来源: Elsevier

【 摘 要 】

Liver transplantation has emerged as a highly efficient treatment for a variety of acute and chronic liver diseases. However, organ shortage is becoming an increasing problem globally, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of losing the graft during transplantation or in the initial postoperative period after liver transplantation (three months). This trend is challenging the model for end-stage liver disease allocation system, where the sickest candidates are prioritised and no delisting criteria are given. The weighting of the deontological demand for equity'', trying to save every patient, regardless of the overall utility; and efficiency'', rooted in utilitarianism, trying to save as many patients as possible and increase the overall quality of life of patients facing the same problem, has to be reconsidered. In this article we are aiming to overcome the widespread concept of futility in liver transplantation, providing a definition of potentially inappropriate liver transplantation and giving guidance on situations where it is best not to proceed with liver transplantation, to decrease the mortality rate in the first three months after transplantation. We propose absolute'' and relative'' conditions, where early post-transplant mortality is highly probable, which are not usually captured in risk scores predicting post-transplant survival. Withholding liver transplantation for listed patients in cases where liver transplant is not deemed clearly futile, but is potentially inappropriate, is a far-reaching decision. Until now, this decision had to be discussed extensively on an individual basis, applying explicit communication and conflict resolution processes, since the model for end-stage liver disease score and most international allocation systems do not include explicit delisting criteria to support a fair delisting process. More work is needed to better identify cases where transplantation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, following a societal debate on what we owe to all liver transplant candidates. (C) 2017 European Association for the Study of the Liver. Published by Elsevier B.V. All rights reserved.

【 授权许可】

Free