Liver Transplantation

Liver Transplant Workup – Lauren Evers Carlini


  • 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




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)

  • 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