First, Do No Harm

Pre-liver transplant patients have a unique clinical situation. Their cirrhosis is irreversible; the only way to treat the underlying cause of their problems is a liver transplant. But unlike other therapies, transplants are unpredictable; a "patient" (pun not intended) might have to wait two days or a month to get their transplant. Even worse, they may have a complication that takes them off the transplant list before they can get an organ. In our hospital, we have far more patients than organs so that those who get the organ have been waiting a long time, and consequently, have far more advanced disease.

Liver disease invites complications. If the liver cannot clear the evil humours in the blood, patients get confused which begets more complications. Cirrhosis decouples blood pressure regulatory mechanisms, it invites pulmonary arterio-venous malformation development, it changes pressures in the brain. The gastrointestinal system becomes engorged with blood, leading to risk for bleeding. The liver stops producing proteins and platelets that stop bleeding. If the liver's synthesis of anti-infectious agents wanes, then infectious become more common and more deadly. The liver's function is intricately tied to the kidney, and when the liver starts failing, the kidney is at risk to do so as well.

We see all these complications in our pre-transplant patients, and as their disease progresses, they come up to the ICU. They come because their confusion requires intubation, their infections require brood spectrum antibiotics, their gastrointestinal bleeds require massive transfusions, their kidneys require continuous dialysis, their blood pressures require continuous vasopressor support. But the most important thing for us to remember is for these patients especially, first do no harm. Our ultimate goal is to get them the transplant, so we have to be cognizant of every risk the patient is exposed to. If we place a central line that gets infected, if we give antibiotics that lead to a Clostridium dificile infection, if we fail to protect their kidneys, if we don't give adequate nutrition, they may lose their place on the transplant list. In contrast to the other patients in the ICU whose diseases we can reverse and who we can get better, we only hope to keep our pre-transplant patients where they are so they can get an organ.

It does work and amazingly so. A woman with alcoholic cirrhosis was on my ICU service three weeks getting daily transfusions and continuous dialysis. After waiting day after day, she finally got a liver. She was walking the second day after surgery and left the ICU four days after her transplant. We expect her kidneys to get better. She has a new life.

Both images are in the public domain, from Wikipedia. First image is a healthy liver. Second image shows cirrhosis.