1. Acute Liver Failure
Anand Annamalai

2. Incidence & Etiology
Lee et al

3. Multi-organ Failure
Nevens et al

4. Cerebral Edema

5. Potential Predictors of Poor Prognosis in Acute Liver Failure

6. STATUS 1A - UNOS

7. LIVER TRANSPLANTATION AS THE GOLD STANDARD FOR ASSESSING ALTERNATE STRATEGIES TO MANAGE ACUTE LIVER FAILURE

8. Survival
Before the option of liver transplant and advanced intensive unit care, the overall survival in the US was 10-20%
Now, with advancements in ICU management transplant-free survival is 40%

9. Survival
Overall survival with both transplantation and ICU management is >60%

10. Cadaveric Transplantation Survival Rates

11. Similar Survival Trend in Liver Transplantation after 1 year between ALF and cirrhosis

12. Predictors of poor prognosis
No proven model exists to accurately predict who will benefit from transplantation
Inaccurate selection may have serious effects:
survival without OLT?
mortality without OLT?
Leads to unnecessary surgery, lifelong immunosuppression, utilization of a scarce resource (hepatic graft) vs death

13. Factors Affecting Outcome of Emergency Transplantation
Age < 50
Age related reduction in physiological reserve associated with extreme stress in ALF
Severity of Illness
Acetaminophen 2x higher mortality after OLT compared to other etiologies
Graft quality
Small size, ABO-incompatibility, steatosis

14. Cadaveric Transplantation US Acute Liver Failure Study Group
Listing guidelines vary from institution to institution
Too sick to list?
Regional differences in organ shortage?
Unclear how many listed patients would survive without OLT?
Those that died off the OLT list deemed not sick enough may benefit from OLT?
Some report > 20 % of transplanted patients would have survived without OLT

15. “To Do” OR “To Not To Do”

16. Anhepatic State: Bridge to OLT
Removal of “dead” liver decreases toxin
load and inflammatory response transiently
Improves until systemic toxins accumulate
Survival of hours

17. The Tough Decision Time is of the essence Unpredictability of outcome
Emergent transplantation for survival
Unpredictability of outcome
Utility of organs in limited supply
May have had better outcome in another patient
Need to consider all organs