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When to Consider Liver Transplant

for Health Care Providers

When to Consider Referral for Liver Transplant Evaluation - Liver Transplant

Appropriate timing of the initial referral for transplant evaluation is critical for optimal care of patient with cirrhosis.

Key concepts

  • There are 2 phases of cirrhosis: compensated and decompensated
  • Decompensated cirrhosis carries a poor prognosis with few options for improvement of the underlying liver failure other than transplant
  • Median survival of patients with compensated cirrhosis is >12 years
  • Median survival of patients with decompensated cirrhosis is 2 years
  • Transition from the compensated phase to the decompensated phase occurs at a rate of 5-7 percent per year
  • Patients may be eligible for liver transplant if they have advanced decompensated cirrhosis, or compensated cirrhosis with certain conditions such as liver cancer (hepatocellular carcinoma, HCC)

Key recommendations

  • Long-term management of patients with cirrhosis should include regular, repeated calculation of the MELD-sodium score to continually assess appropriate time for transplant referral
  • Comprehensive care of patients with cirrhosis should include:
    • Discussions with patients to remain mindful of the potential eventual need for a liver transplant
    • Efforts to optimize medical, social, and behavioral factors relevant to liver transplant

Criteria for transplantation referral

  • Child-Turcotte-Pugh score ≥7
  • MELD-sodium score: optimal timing for first referral is MELD ≥10, and definitely by MELD ≥15
  • First development of any decompensation event: ascites, variceal bleeding, or hepatic encephalopathy
  • HCC without metastasis or macrovascular invasion; patients with HCC and cirrhosis (either compensated or decompensated) should be referred for transplant evaluation

Conditions warranting expedited transplantation referral

  • Fulminant hepatic failure (critical care management)
  • Hepatopulmonary syndrome
  • Hepatorenal syndrome type 1

Some contraindications to liver transplant

  • Severe cardiac or pulmonary disease
  • Ongoing alcohol or illicit substance abuse
  • Persistent noncompliance
  • Lack of adequate social support system

Some areas a referring physician can help patients to manage prior to transplant evaluations

  • Alcohol
  • Smoking
  • Obesity
  • Illicit drug use
  • Social support
  • Osteoporosis
  • Coronary artery disease
  • Hepatitis C infection
  • Hepatitis B infection
  • Pulmonary disease
  • Depression and anxiety
  • Diabetes mellitus
  • Chronic opioid use
  • Hyperlipidemia
  • HIV infection
  • Medical adherence

Conditions that do not necessarily make patients ineligible for transplant

  • Methadone maintenance
  • Older age (>70 years)
  • History of extrahepatic malignancy that has received definitive treatment
  • Cholangiocarcinoma