Liver Transplant (LT) Workup¶
Lauren Evers Carlini
- Model for End-stage Liver Disease (MELD-Na) score: initially developed to predict survival following TIPS placement, though is now used to objectively rank patients in terms of priority for liver transplant (LT)
- 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
- Listing a patient for LT is determined by a multidisciplinary transplant
- 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*|
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: EKG and TTE with bubble are required. Functional testing: CT coronaries with fractional flow, invasive angiography and intervention may be necessary depending on pre-test probability.
PFT’s, carotid ultrasound, panorex, etc.
Appropriate cancer screenings (colonoscopy, pap smear, mammogram, and PSA if applicable)
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)
Current VUMC policy: pts should be abstinent from alcohol no less than 3-6 months, although exceptions may be m ade for early liver transplant based on a very strict protocol. Discuss exception criteria iwth attending if suspect patient unlikely to survive hospitalization without transplant
Both living and deceased donor transplant are offered at VUMC. Donor evaluation, however, cannot be started before the potential recipient is deemed a candidate