The end stage of years of repetitive cycles of inflammation and repair is advanced fibrosis and cirrhosis with the attendant complications, which are challenging to treat and which seriously affect patients’ quality of life. Additionally, end stage cirrhotic liver disease is associated, of course, with the development of hepatocellular cancer.
Transplantation represents a real success story of the latter part of the 20th century because it has transformed the prognosis of diseases which until comparatively recently were considered fatal.
By definition, this group of patients has an appalling prognosis. Patients with end-stage liver disease require increasingly complex medical support and manifest a spectrum of complications that significantly impact on quality of life, such as the development of ascites, encephalopathy, and cachexia.
At the same time, the flexibility to deploy pharmaceutical-based approaches is limited by the capacity of the end stage diseased liver to metabolize many drugs commonly used in advanced disease, such as opiates.
Patients with compensated chronic liver failure (without ascites, variceal bleeding, encephalopathy, or jaundice) have a median survival of 12 years. After decompensation, median survival drops to ~ 2 years.
The hepatorenal syndrome (HRS) – renal failure from renal arterial underfilling due to decompensated liver failure – portends a particularly poor prognosis. Most patients with type-1 HRS (rapid and severe renal failure) die within 8-10 weeks even with therapy. Median survival with type-2 HRS (chronic, less severe renal failure with serum creatinine usually 1.5-2 mg/dL) is around 6 months.
Both older age and hepatocellular carcinoma also adversely affect survival.