Introduction

Orthotopic liver transplantation is the accepted therapeutic option of choice for acute and chronic end-stage liver disease. The indications and contraindications to liver transplantation have become standardized, as has the operative and postoperative management. This chapter will address the evaluation and management of patients with acute and chronic liver failure with particular emphasis on recipient selection, operative and postoperative management, and will consist of a practical approach to patients undergoing liver transplantation. Our goal is to provide helpful guidelines to caregivers involved in the care of these complex patients.

Liver failure can present as either acute (fulminant and subfulminant failure) or chronic (advanced cirrhosis). The term decompensated cirrhosis reflects the presence of one or more complications. Each disease etiology presents unique features and it is therefore important to recognize these distinctions. In the pre-transplantation era, liver failure was associated with an almost universal fatal outcome, with a spontaneous survival in fulminant hepatic failure of 10-20% and a 1 year mortality in decompensated cirrhosis of >50%. In contrast, liver transplantation patient survival outcomes are presently >85% at one year and >70% at five years, underlining the application of liver transplantation as the standard of care in patients with both acute and chronic liver failure. In addition, the advent of both split liver transplant and live-donor liver transplantation offers additional hope to patients with liver failure in the presence of an ever-growing cadaveric organ shortage.

A. Liver Transplantation for Patients with Acute Liver Failure

Acute liver failure (ALF) is often used synonymously with fulminant liver failure. ALF is defined as an acute hepatic deterioration not preceded by evidence of chronic liver disease, which has progressed from the onset of jaundice to the development of hepatic encephalopathy in less than 8 weeks.1

Subsequent refinements include a division between fulminant (<2 weeks) and subfulminant hepatic failure (>2weeks), a difference that reflects the greater predominance of brain edema and intracranial hypertension in patients with a shorter interval between the onset of jaundice and the development of encephalopathy. More recently, a differentiation between hyperacute (< lweek), acute (1-4 wks) and subacute failure (>4 wks) has been suggested. Both drug-induced hepatic failure and an indeterminate etiology appear to be more commonly associated with a longer interval. There are also geographic differences in the etiology of

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