Liver Transplant (LT) Workup¶
Lauren Evers Carlini
Background¶
- 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
committee
- 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¶
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Abdominal CT (triple phase) or MRI (multiphase with contrast) to evaluate for hepatic malignancy and vascular anatomy
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Infectious workup: TB testing, HIV, RPR, VZV, CMV, EBV, and Hepatitis A, B, and C.
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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.
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PFT’s, carotid ultrasound, panorex, etc.
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Appropriate cancer screenings (colonoscopy, pap smear, mammogram, and PSA if applicable)
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DEXA scan
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Certification of completion of intensive outpatient program (IOP) for substance abuse
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Evaluation by hepatobiliary surgical team after obtaining cross sectional imaging
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Psychosocial evaluation (consult Psychiatry, social work)
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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
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Both living and deceased donor transplant are offered at VUMC. Donor evaluation, however, cannot be started before the potential recipient is deemed a candidate