Gastroenterology

Gastroenterology

Volume 134, Issue 6, May 2008, Pages 1764-1776
Gastroenterology

Introduction
Indications for Liver Transplantation

https://doi.org/10.1053/j.gastro.2008.02.028Get rights and content

Patients should be considered for liver transplantation if they have evidence of fulminant hepatic failure, a life-threatening systemic complication of liver disease, or a liver-based metabolic defect or, more commonly, cirrhosis with complications such as hepatic encephalopathy, ascites, hepatocellular carcinoma, hepatorenal syndrome, or bleeding caused by portal hypertension. While the complications of cirrhosis can often be managed relatively effectively, they indicate a change in the natural history of the disease that should lead to consideration of liver transplantation. Referral to a liver transplant center is followed by a detailed medical evaluation to ensure that transplantation is technically feasible, medically appropriate, and in the best interest of both the patient and society. Patients approved for transplantation are placed on a national transplant list, although donor organs are allocated locally and regionally. Since 2002, priority for transplantation has been determined by the Model of End-Stage Liver Disease (MELD) score, which provides donor organs to listed patients with the highest estimated short-term mortality.

Section snippets

Referral for Transplant Evaluation

Referral for liver transplant evaluation should be considered for irreversible hepatic failure regardless of cause, complications of decompensated cirrhosis, systemic complications of liver disease, liver cancers, or liver-based metabolic conditions causing systemic disease (Table 1). Of course, the initial step in the evaluation process is this recognition of the need for a transplant and referral to a transplant center by the physician, usually a gastroenterologist. Certainly, many factors

Pretransplant Evaluation

The basic process of evaluation of transplant candidacy is relatively uniform between centers. Liver transplant evaluation generally follows the steps listed in Table 2. This process is necessarily rigorous and strives to answer 3 basic questions. First, are there other options short of transplantation that would serve the patient better or, stated another way, will liver transplantation offer the patient the best chance for long-term survival? Second, are there comorbid medical or psychosocial

Contraindications to Transplantation

Contraindications vary between centers and over time. For example, the initial poor experience with transplantation of patients with hepatitis B led most centers in the United States to abandon transplantation for this indication for several years until hepatitis B immunoglobulin and then antiviral agents became available. Currently, these patients have excellent survival. Similarly, infection with human immunodeficiency virus was an absolute contraindication to transplantation in the past, but

Listing for Transplantation and the Organ Allocation System

The results of the liver transplant evaluation are reviewed in detail by a patient selection committee composed of transplant surgeons, hepatologists, anesthesiologists, psychiatrists or psychologists, transplant coordinators, social workers, and a finance office representative. An oncologist, a cardiologist, or others who might offer insight on a particular case are often included on an ad hoc basis. The purpose of the committee is to determine whether the procedure is medically necessary and

Management While Waiting for Transplantation

All patients on the transplant list should be managed with the assistance of a transplant hepatologist. The aims are obviously to avoid unnecessary complications of cirrhosis, optimize management of complications when they occur, screen for changes in the medical condition such as worsening hepatic function or HCC that might change the priority for transplantation, and, above all, make sure that the patient is in the best possible condition when a donor organ becomes available. Thus, patients

Hepatitis C

Hepatitis C virus (HCV) infects about 1.8% or 3–5 million persons in the United States.10, 11 Up to 20% of HCV-infected patients progress to cirrhosis after 20 years of infection.12 Among patients with HCV-induced cirrhosis, 4% per year decompensate and 1%–4% per year develop HCC.13, 14, 15 The risk of HCC is increasing among HCV-infected patients.16 Five-year survival is only about 50% once hepatic failure has developed, so this is the clinical trigger point for referring patients for

Summary

Patients should be considered for liver transplantation if they have evidence of fulminant hepatic failure, a life-threatening systemic complication of liver disease or a liver-based metabolic defect, or, more commonly, cirrhosis with complications such as hepatic encephalopathy, ascites, HCC, hepatorenal syndrome, or bleeding caused by portal hypertension. While the complications of cirrhosis can often be managed relatively effectively, they indicate a change in the natural history of the

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