General features

Endstage liver disease affects virtually every other organ system. The pretransplant condition of patients with endstage liver disease makes them more vulnerable to postoperative multiple organ failure. They usually demonstrate a hyperdynamic circulation, with a poor nutritional and immune state. Portal hypertension may contribute to impaired gut barrier function allowing translocation of enteric organisms or their toxic products. Acute complications may occur rapidly, including infections such as spontaneous peritonitis, cerebral depression from the injudicious use of sedative drugs, and gastrointestinal bleeding from varices or ulceration, all of which may result in further hemodynamic and cerebral decompensation.

Short-term outcome following orthotopic liver transplantation depends on the etiology (mortality is higher for hepatitis B and non-A non-B hepatitis) and on preoperative morbidity. In patients with rapidly deteriorating liver failure, adverse prognostic indicators include acidemia, grade III or more encephalopathy, prothrombin time greater than 100 s and serum creatinine greater than 300 pmol/l. Ideally, transplantation should be performed before complications occur, since they reduce the chances of success and may be impossible to reverse even after transplantation.

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