Liver Transplantation

Liver Transplant Workup – Lauren Evers Carlini

Background

  • Model for End-stage Liver Disease (MELD) score: initially developed to predict survival following TIPS placement, though is now used to objectively rank patients in terms of priority for liver transplant; factors in total bilirubin, creatinine, and INR. An updated version, the MELD-Na score, factors in the serum Na as well.
    • Exception points given for complications like HCC and hepatopulmonary syndrome (HPS), leading to score in mid to high 20’s even if biologic MELD is low
  • Whether to list a pt for LT is determined by a multidisciplinary transplant committee (if interested, ask fellow/attending if you can sit in on meeting)
    • The United Network for Organ Sharing (UNOS) manages and monitors the process.
    • US is divided into 11 geographic regions; organs are allocated within each
    • Acute liver failure pts take precedence over decompensated cirrhosis pts for LT

 

Indications

Contraindications*

Cirrhosis with MELD 15 or evidence of decompensation (ascites, variceal bleed, HE, HPS, portopulmonary HTN)

Ongoing substance abuse (must have documented abstinence ≥ 3 mos); some special considerations for pts who did not know of EtOH hepatitis or EtOH use d/o but highly variable

Acute Liver Failure

Untreated or recurrent malignancy

HCC that meets Milan criteria

Active Infection, AIDS

Pts with early hilar cholangio-carcinoma that meets specific criteria

Documented history of medical noncompliance

Other rare dz (e.g., familial amyloid polyneuropathy or hyperoxaluria)

Lack of Adequate social support

 

Anatomic Contraindications; Chronic cardiac/pulmonary conditions that significantly increase perioperative risk (e.g., severe pulm HTN)

*Advanced age (>70) is not in itself a contraindication but candidates > 70 should be almost free of comorbidities to be considered for LT

 

Evaluation (ask upper level or fellow for detailed document)

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  • Determine cause of cirrhosis or acute liver failure, if not done already
  • Abdominal CT (triple phase) or MRI (multiphase with contrast) to evaluate for hepatic malignancy and vascular anatomy.
  • Infectious workup: TB testing, HIV, RPR, VZV, CMV, EBV, and Hepatitis A, B, and C.
  • Cardiac evaluation (typically starts with non-invasive testing; TTE plus dobutamine stress echo are preferred). Coronary angiography and intervention may be necessary if significant CAD is suggested (pts with DM or atherosclerosis on abdominal/carotid imaging) or pts with multiple risk factors (e.g. age 45M, FF W), NASH, hx smoking
  • PFT’s
  • Appropriate cancer screenings (colonoscopy, pap smear, MMG, and PSA if applicable)
  • DEXA scan
  • Certification of completion of intensive outpatient program (IOP) for substance abuse
  • Evaluation by hepatobiliary surgical team after obtaining cross sectional imaging
  • Psychosocial evaluation (consult Psychiatry, social work)
  • Both living and deceased donor transplant are offered at VUMC. Donor evaluation, however, cannot be started before the potential recipient is deemed a candidate