Header

UZH-Logo

Maintenance Infos

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


Linecker, Michael; Krones, Tanja; Berg, Thomas; Niemann, Claus U; Steadman, Randolph H; Dutkowski, Philipp; Clavien, Pierre-Alain; Busuttil, Ronald W; Truog, Robert D; Petrowsky, Henrik (2018). Potentially inappropriate liver transplantation in the era of the "sickest-first" policy - a search for the upper limits. Journal of Hepatology, 68(4):798-813.

Abstract

Liver transplantation has emerged to a highly efficient treatment for a variaty of acute and chronic liver diseases. Organ shortage, however, is becoming an increasing problem worldwide, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of loosing the graft during transplantation or in the initial post-operative period after liver transplantation (3 months). This trend is challenging the MELD allocation model where sickest candidates are prioritized and no delisting criteria are given. The weighing of two conflicting bio-ethical concepts, 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 at overcoming the widespread and wide concept of futility in liver transplantation, provide a definition of potentially inappropriate liver transplantation and give decision guidance in which situations not to proceed with liver transplantion to decrease the mortality rate in the first 3 months after transplanation. “Absolute” and “relative” conditions, when early posttransplant mortality is highly probable, are proposed, usually not captured in risk scores predicting post-transplant survival. Withholding listed patients for the chance of liver transplantation, who are assessed as not being clearly futile but potentially inappropriate, is a far-reaching decision. Up to now, this decision has to be extensively discussed on a individual basis, applying explicit communication and conflict resolution processes, since the MELD score and most international allocation systems do not include explicit delisting criteria for supporting a fair delisting process. More work is needed to better identify liver transplant candidates where transplanation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, triggered by a societal debate on what we owe to all liver transplant candidates.

Abstract

Liver transplantation has emerged to a highly efficient treatment for a variaty of acute and chronic liver diseases. Organ shortage, however, is becoming an increasing problem worldwide, limiting the applicability of liver transplantation. In addition, potential recipients are becoming sicker, thereby increasing the risk of loosing the graft during transplantation or in the initial post-operative period after liver transplantation (3 months). This trend is challenging the MELD allocation model where sickest candidates are prioritized and no delisting criteria are given. The weighing of two conflicting bio-ethical concepts, 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 at overcoming the widespread and wide concept of futility in liver transplantation, provide a definition of potentially inappropriate liver transplantation and give decision guidance in which situations not to proceed with liver transplantion to decrease the mortality rate in the first 3 months after transplanation. “Absolute” and “relative” conditions, when early posttransplant mortality is highly probable, are proposed, usually not captured in risk scores predicting post-transplant survival. Withholding listed patients for the chance of liver transplantation, who are assessed as not being clearly futile but potentially inappropriate, is a far-reaching decision. Up to now, this decision has to be extensively discussed on a individual basis, applying explicit communication and conflict resolution processes, since the MELD score and most international allocation systems do not include explicit delisting criteria for supporting a fair delisting process. More work is needed to better identify liver transplant candidates where transplanation is potentially inappropriate and to integrate and discuss these delisting criteria in allocation systems, triggered by a societal debate on what we owe to all liver transplant candidates.

Statistics

Citations

Dimensions.ai Metrics

Altmetrics

Additional indexing

Item Type:Journal Article, refereed, original work
Communities & Collections:04 Faculty of Medicine > University Hospital Zurich > Clinic for Visceral and Transplantation Surgery
Dewey Decimal Classification:610 Medicine & health
Language:English
Date:2018
Deposited On:09 Jan 2018 16:04
Last Modified:16 Mar 2018 02:02
Publisher:Elsevier
ISSN:0168-8278
OA Status:Closed
Publisher DOI:https://doi.org/10.1016/j.jhep.2017.11.008
PubMed ID:29133246

Download

Full text not available from this repository.
View at publisher

Get full-text in a library