A REGIONAL EXPERIENCE WITH EMERGENCY LIVER-TRANSPLANTATION

Liver transplantation for patients requiring life-support results in t he lowest survival and highest costs. A ten year (1983-1993) regional experience with liver transplantation for critically ill patients was undertaken to ascertain the fate of several subgroups of patients, Of the 828 liver transplants performed at six transplant centers within t he region over this period, 168 (20%) were done in patients who met to day's criteria for a United Network of Organ Sharing (UNOS) status 1 ( emergency) liver transplant candidate. Recipients were classified acco rding to chronicity of disease and transplant number (primary-acute, p rimary-chronic, reTx-acute, reTx-chronic). Overall one-year survival w as 50% for all status 1 recipients. The primary-acute subgroup (n=63) experienced a 57% one-year survival compared with 50% for the primary- chronic (n=51) subgroup (P=0.07). Of the reTx-acute recipients (n=43), 44% were alive at one year in comparison with 20% for the reTx-chroni c (n=11) group (P=0.18), There was no significant difference in surviv al for the following: transplant center, blood group compatibility wit h donors, age, preservation solution, or graft size. For patients retr ansplanted for acute reasons (primary graft nonfunction (PGNF) or hepa tic artery thrombosis [HAT]), survival was significantly better if a s econd donor was found within 3 days of relisting (52% vs, 20%; P=0.012 ). Over the study period progressively fewer donor organs came from ou tside the region. No strong survival-based argument can be made for se parating, in allocation priority, acute and chronic disease patients f acing the first transplant as a status 1 recipient. Clearly patients s uffering from PONE or HAT do far better if retransplanted within 3 day s. Establishing an even higher status for recipients with PGNF, perhap s drawing from a supraregional donor pool, would allow surgeons to acc ept more marginal donors, thus potentially expanding the pool, without significantly compromising patient survival. Retransplantation of the recipient with a chronically failing graft who deteriorates to the po int of needing life-support is nearly futile, and in today's health ca re climate, not an optimal use of scarce donor livers.