Potentially inappropriate liver transplantation in the era of the "sickest first" policy - A search for the upper limits.
- Linecker M Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland.
- Krones T Division of Clinical Ethics, University Hospital Zurich, Switzerland; Institute of Biomedical Ethics and History of Medicine, University of Zurich, Switzerland.
- Berg T Division of Hepatology, University of Leipzig, Germany.
- Niemann CU Department of Anesthesiology, University of California, San Francisco, USA; Department of Surgery, University of California San Francisco, USA.
- Steadman RH Department of Anesthesiology and Perioperative Medicine, Ronald Reagan Medical Center, University of California Los Angeles, Los Angeles, USA.
- Dutkowski P Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland.
- Clavien PA Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland.
- Busuttil RW Dumont-UCLA Transplant Center, Ronald Reagan Medical Center, University of California Los Angeles, USA.
- Truog RD Center for Bioethics, Harvard Medical School, Boston, USA; Department of Anesthesia, Perioperative and Pain Medicine, Boston Children's Hospital, USA.
- Petrowsky H Swiss HPB and Transplantation Center, University Hospital Zurich, Switzerland; Department of Surgery and Transplantation, University Hospital Zurich, Switzerland. Electronic address: Henrik.Petrowsky@usz.ch.
- 2017-11-15
Published in:
- Journal of hepatology. - 2018
ACLF
ALF
CLF
Efficiency
Equity
Futile
Liver transplant
Organ shortage
End Stage Liver Disease
Humans
Hypertension, Pulmonary
Liver Failure, Acute
Liver Transplantation
Severity of Illness Index
Tissue and Organ Procurement
Waiting Lists
English
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.
- Language
-
- English
- Open access status
- bronze
- Identifiers
-
- DOI 10.1016/j.jhep.2017.11.008
- PMID 29133246
- Persistent URL
- https://folia.unifr.ch/global/documents/259568
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