Reply

We thank Levesque et al. for all of their kind comments and for pointing out important findings of our study. In response to their comments, we would like to make the following remarks. We agree that the selection of patients with liver cirrhosis and intensive care unit (ICU) admission for liver transplantation is of great importance. The term “selection bias” might be misleading in this context because the correct selection of patients who are likely to have a good outcome after transplantation is the key to successful transplant of this difficult patient population. In our series, liver transplantation was only considered in ICU patients if the fraction of inspired oxygen was 40%, with a positive end-expiratory pressure 10 and low pressor requirements (Levophed, 0.10 ug/kg/minute; Vasopressin, 2.4 u/hour) in the absence of active infection. Patients not fulfilling these criteria were declined liver transplantation with an overall poor outcome. Our study was focused on transplantation of ICU-requiring versus non-ICU-requiring patients, and we did not investigate ICU-bound patients with liver cirrhosis not proceeding with liver transplantation. As pointed out by Levesque et al., neither pretransplant Model for End-Stage Liver Disease nor sequential organ failure assessment score predicted outcome after liver transplantation of ICU-bound patients. Indeed, posttransplant liver function was identical in ICU-bound (intubated and not intubated) and non-ICU-dependent recipients. We observed that ICU-dependent patients with cirrhosis requiring intubation with a Glasgow coma scale of<7 had a significantly worse outcome with a 1-year mortality of 38%. Considering the limited availability of donor organs, prospective studies evaluating risk factors for liver transplantation will be difficult to perform. Levesque et al. report a smaller series of ICU-dependent patients undergoing liver transplantation with similar findings. The small sample size in their series, the lack of a control group, and the relatively short 3-month survival highlights the problems with studying this patient population. Larger multicenter studies are required to better define risk factors and indications for liver transplantation in these critically ill patients.