Liver Transplantation for Acute Liver Failure: Not Too Early But Never Too Late

Acute liver failure is a catastrophic illness that can rapidly progress to death in a previously healthy person with no known liver disease.Treatment is generally supportive, but the outcome is unpredictable.Although a variable proportion of patients can recover spontaneously, others may continue to deteriorate, and in such cases, liver transplantation is the only effective treatment.The rapidly progressive course of the disease, however, allows only a very narrow window for the application of liver transplantation.In order to avoid unnecessary transplants in those who would survive and to prevent unavailable transplants in those who would not survive, liver transplantation needs to be done at the optimal time, not too early but never too late.Unfortunately, the timing of deceased donor liver transplantation is dictated entirely by the availability of a liver graft.Various prognostic indicators have been suggested for the prediction of the outcome of acute liver failure to allow early identification and listing of those who would not survive without a transplant.In addition, patients with acute liver failure are generally given the top priority for graft allocation.Nonetheless, every transplant team must have faced the dilemma of whether to transplant an available graft into a patient with acute liver failure who has not yet fulfilled the criteria for transplantation or who has deteriorated to the point at which transplantation may be futile.Furthermore, as a last resort to save desperately ill patients, high-risk grafts such as extremely marginal or ABO-incompatible ones are frequently used, and this partly contributes to the inferior outcome of transplantation in these patients.In countries such as those in Asia where deceased organ donors are scarce, deceased