Liver Disease II

Many patients get transferred from outside hospitals to our ICU for evaluation for liver transplant. As the medical ICU fellow, my job is to optimize these patients as best I can for potential surgery and prevent ICU complications while the determination of their transplant candidacy happens. Transplant eligibility is determined by each individual institution by a group of medical hepatologists and transplant surgeons. The United Network for Organ Sharing distributes organs within a geographic region based on blood type and the recipient's disease severity (their MELD score). Unfortunately, in our geographic area, we have so many people on the list and so few organs that by the time patients reach the top of the list, they are critically ill.

I think this creates a lot of problems. I see patients with widespread rampaging infections, severe encephalopathy, respiratory failure, circulatory shock states, renal injury, disseminated bleeding, and other liver complications. They are often too sick to survive transplant, and sometimes, too sick to even survive in the ICU. Once the liver completely fails, time starts ticking as the patient runs into one complications after another. Even as I staunch each problem, another one springs up. We've had several patients who were being considered for transplant who were declined an organ because they were too sick to survive. Sometimes, transplant eligibility is denied because of other factors such as ongoing drinking or poor social support. Ultimately, though, a substantial number of our liver patients pass away from decompensated disease.

I write about this serious topic because it's really affected me as an ICU physician. I think ultimately, the best solution is to increase the organ supply so that potential liver recipients get organs before their disease becomes too tenuous. That may be a topic for a future post. However, for now, I think it is paramount to recognize that liver disease can be a terminal illness and that not everyone can get a liver transplant. By the time someone reaches my care in the ICU, they only have days to weeks to get a new organ before their disease ultimately proves fatal.

Image of cirrhotic liver is in the public domain, from Wikipedia.