Outcomes following liver transplantation in intensive care unit patients

AIM:To determine feasibility of liver transplantation in patients from the intensive care unit (ICU) by estimating graft and patient survival.METHODS:This single center retrospective study included 39 patients who had their first liver transplant directly from the intensive care unit and 927 non-ICU patients who were transplanted from hospital ward or home between January 2005 and December 2010.RESULTS:In comparison to non-ICU patients,ICU patients had a higher model for end-stage liver disease (MELD) at transplant (median:37 vs 20,P < 0.001).Fourteen out of 39 patients (36%) required vasopressor support immediately prior to liver transplantation (LT) with 6 patients (15%) requiring both vasopressin and norepinephrine.Sixteen ICU patients (41%) were ventilator dependent immediately prior to LT with 9 patients undergoing percutaneous tracheostomy prior to transplantation.Twenty-five ICU patients (64%) required dialysis preoperatively.At 1,3 and 5 years after LT,graft survival was 76%,68% and 62% in ICU patients vs 90%,81% and 75% in non-ICU patients.Patient survival at 1,3 and 5 years after LT was 78%,70% and 65% in ICU patients vs 94%,85% and 79% in non-ICU patients.When formally comparing graft survival and patient survival between ICU and nonICU patients using Cox proportional hazards regression models,both graft survival [relative risk (RR):1.94,95%CI:1.09-3.48,P=0.026] and patient survival (RR:2.32,95%CI:1.26-4.27,P=0.007) were lower in ICU patients vs non-ICU patients in single variable analysis.These findings were consistent in multivariable analysis.Although not statistically significant,graft survival was worse in both patients with cryptogenic cirrhosis (RR:3.29,P=0.056) and patients who received donor after cardiac death (DCD) grafts (RR:3.38,P=0.060).These findings reached statistical significance when considering patient survival,which was worse for patients with cryptogenic cirrhosis (RR:3.97,P=0.031) and patients who were transplanted with DCD livers (RR:4.19,P=0.033).Graft survival and patient survival were not significantly worse for patients on mechanical ventilation (RR:0.91,P=0.88 in graft loss;RR:0.69,P=0.56 in death) or patients on vasopressors (RR:1.06,P=0.93 in graft loss;RR:1.24,P=0.74 in death) immediately prior to LT.Trends toward lower graft survival and patient survival were observed for patients on dialysis immediately before LT,however these findings did not approach statistical significance (RR:1.70,P=0.43 in graft loss;RR:1.46,P=0.58 in death).CONCLUSION:Although ICU patients when compared to non-ICU patients have lower survivals,outcomes are still acceptable.Pre-transplant ventilation,hemodialysis,and vasopressors were not associated with adverse outcomes.