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Liver transplant failure — Clinical Guidelines

Overview

Liver transplant failure refers to the deterioration or loss of liver graft function post-transplantation, often leading to complications such as multiple organ dysfunction syndrome (MODS) and increased mortality rates, particularly in cases of acute liver failure (ALF) and acute-on-chronic liver failure (ACLF). 1 2 3

Diagnosis

Clinical Presentation: Rapid rise in ALT levels, encephalopathy, prolonged INR. 25

Diagnostic Criteria: Utilize definitions from APASL for ACLF, focusing on acute precipitants in chronic liver disease context. 11

Recommended Tests: Comprehensive metabolic panel, coagulation studies, imaging (e.g., ultrasound), and liver function tests. 20

Grading: Use grading systems like the MELD score for prognostic assessment post-transplant failure. 8

Management

First-Line Treatments:

- Supportive Care: Management of fluid balance, electrolyte disturbances, and hemodynamics. 23 28 - Infection Control: Prophylactic and therapeutic antibiotics to prevent or treat infections. 2 4

Adjunctive Therapies:

- Artificial Support Systems: Molecular Adsorbents Recirculating System (MARS) for cytokine and endotoxin removal. 18 - Extracorporeal Therapies: Continuous Renal Replacement Therapy (CRRT) for combined liver and renal failure. 23 - Bioartificial Liver Support: Hybrid bioartificial liver (HBL) for cytokine clearance and SIRS management. 17

Special Populations

Pediatrics: Living donor liver transplantation (LDLT) can be considered in critically ill children with multiple organ system failure, though outcomes vary. 22

Elderly: Specific considerations for fluid and electrolyte management in elderly patients with liver failure and concurrent conditions like acute pancreatitis. 28

Key Recommendations

Implement Comprehensive Supportive Care: Address fluid, electrolyte, and hemodynamic management to stabilize patients post-transplant failure. (Evidence: Moderate 23 28)

Utilize Artificial Support Systems: Employ MARS or CRRT in severe cases to mitigate MODS and improve outcomes. (Evidence: Moderate 18 23)

Consider Bioartificial Liver Support: Use hybrid bioartificial liver support systems to manage systemic inflammatory response and cytokine storm. (Evidence: Weak 17)

Tailor Management to Patient Age and Comorbidities: Adjust treatment strategies based on patient-specific factors such as pediatric status or elderly frailty. (Evidence: Expert opinion 22 28)

References

1 Guo H, Yin N, Liu J, Li A. Acute versus acute-on-chronic liver failure: comparative analysis of clinical outcomes in Beijing, China. BMC gastroenterology 2025. link 2 Nanchal R, Subramanian R, Alhazzani W, Dionne JC, Peppard WJ, Singbartl K et al.. Guidelines for the Management of Adult Acute and Acute-on-Chronic Liver Failure in the ICU: Neurology, Peri-Transplant Medicine, Infectious Disease, and Gastroenterology Considerations. Critical care medicine 2023. link 3 Torre A, Cisneros-Garza LE, Castillo-Barradas M, Navarro-Alvarez N, Sandoval-Salas R, González-Huezo MS et al.. Consensus document on acute-on-chronic liver failure (ACLF) established by the Mexican Association of Hepatology. Annals of hepatology 2023. link 4 Paugam-Burtz C, Levesque E, Louvet A, Thabut D, Amathieu R, Bureau C et al.. Management of liver failure in general intensive care unit. Anaesthesia, critical care & pain medicine 2020. link 5 Shi R, Long C, Dai Y, Huang Q, Gao Y, Zhang N et al.. Bongkrekic acid poisoning: Severe liver function damage combined with multiple organ failure caused by eating spoiled food. Legal medicine (Tokyo, Japan) 2019. link 6 Krawczyk M. History of liver transplantation in Poland. Polski przeglad chirurgiczny 2018. link 7 Kozlov AV, Lancaster JR, Meszaros AT, Weidinger A. Mitochondria-meditated pathways of organ failure upon inflammation. Redox biology 2017. link 8 Graziadei I, Zoller H, Fickert P, Schneeberger S, Finkenstedt A, Peck-Radosavljevic M et al.. Indications for liver transplantation in adults : Recommendations of the Austrian Society for Gastroenterology and Hepatology (ÖGGH) in cooperation with the Austrian Society for Transplantation, Transfusion and Genetics (ATX). Wiener klinische Wochenschrift 2016. link 9 Uygun BE, Yarmush ML, Uygun K. Application of whole-organ tissue engineering in hepatology. Nature reviews. Gastroenterology & hepatology 2012. link 10 Soga K, Tomikashi K, Fukumoto K, Miyawaki K, Okuda K, Konishi H et al.. Successful endoscopic hemostasis for ruptured duodenal varices after balloon-occluded retrograde transvenous obliteration. Digestive endoscopy : official journal of the Japan Gastroenterological Endoscopy Society 2010. link 11 Duseja A, Chawla YK, Dhiman RK, Kumar A, Choudhary N, Taneja S. Non-hepatic insults are common acute precipitants in patients with acute on chronic liver failure (ACLF). Digestive diseases and sciences 2010. link 12 Landsman IS, Karsanac CJ. Case report: pediatric liver retransplantation on an extracorporeal membrane oxygenation-dependent child. Anesthesia and analgesia 2010. link 13 Nieuwoudt M, Engelbrecht GH, Sentle L, Auer R, Kahn D, van der Merwe SW. Non-toxicity of IV injected perfluorocarbon oxygen carrier in an animal model of liver regeneration following surgical injury. Artificial cells, blood substitutes, and immobilization biotechnology 2009. link 14 Eason JD, Gonwa TA, Davis CL, Sung RS, Gerber D, Bloom RD. Proceedings of Consensus Conference on Simultaneous Liver Kidney Transplantation (SLK). American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons 2008. link 15 Burra P, Tomat S, Villa E, Gasbarrini A, Costa AN, Conconi MT et al.. Experimental hepatology applied to stem cells. Digestive and liver disease : official journal of the Italian Society of Gastroenterology and the Italian Association for the Study of the Liver 2008. link 16 Ringe B, Xiao G, Sass DA, Karam J, Shang S, Maroney TP et al.. Rescue of a living donor with liver transplantation. American journal of transplantation : official journal of the American Society of Transplantation and the American Society of Transplant Surgeons 2008. link 17 Liu Q, Duan ZP, Huang C, Zhao CH. Evaluation of effect of hybrid bioartificial liver using end-stage liver disease model. World journal of gastroenterology 2004. link 18 Guo LM, Liu JY, Xu DZ, Li BS, Han H, Wang LH et al.. Application of Molecular Adsorbents Recirculating System to remove NO and cytokines in severe liver failure patients with multiple organ dysfunction syndrome. Liver international : official journal of the International Association for the Study of the Liver 2003. link 19 Liu J, Kjaergard LL, Als-Nielsen B, Gluud C. Artificial and bioartificial support systems for liver failure: a Cochrane Hepato-Biliary Group Protocol. Liver 2002. link 20 Kelly DA. Managing liver failure. Postgraduate medical journal 2002. link 21 Kozaki K, Kasahara M, Oike F, Ogawa K, Fujimoto Y, Ogura Y et al.. Apheresis therapy for living-donor liver transplantation: experience for apheresis use for living-donor liver transplantation at Kyoto University. Therapeutic apheresis : official journal of the International Society for Apheresis and the Japanese Society for Apheresis 2002. link 22 Mack CL, Ferrario M, Abecassis M, Whitington PF, Superina RA, Alonso EM. Living donor liver transplantation for children with liver failure and concurrent multiple organ system failure. Liver transplantation : official publication of the American Association for the Study of Liver Diseases and the International Liver Transplantation Society 2001. link 23 Davenport A. Is there a role for continuous renal replacement therapies in patients with liver and renal failure?. Kidney international. Supplement 1999. link 24 Sussman NL, Lake JR. Treatment of hepatic failure--1996: current concepts and progress toward liver dialysis. American journal of kidney diseases : the official journal of the National Kidney Foundation 1996. link90094-3) 25 McCaughan GW, Huynh JC, Feller R, Painter D, Waugh R, Sheil AG. Fulminant hepatic failure post liver transplantation: clinical syndromes, correlations and outcomes. Transplant international : official journal of the European Society for Organ Transplantation 1995. link 26 Lerut J, Gertsch P, Blumgart LH. "Piggy back" adult orthotopic liver transplantation. Helvetica chirurgica acta 1989. link 27 Matsubara S, Okabe K, Ouchi K, Sato T, Matsuno S. Temporary metabolic support by extracorporeal blood therapy for liver failure after surgery. ASAIO transactions 1988. link 28 Adinaro D. Liver failure and pancreatitis. Fluid and electrolyte concerns. The Nursing clinics of North America 1987. link 29 Sherlock S. Hepatic transplantation. Southern medical journal 1987. link 30 Read AE. Some clinical features of liver cell failure: an appraisal of their causes. Gut 1978. link

Liver transplant failure