Alyson J. Kaplan1, Nicole T. Shen2, Alyson N. Fox2, and Robert S. Brown Jr1 1 Department of Gastroenterology and Hepatology, New York Presbyterian Weill Cornell Medical Center, New York, USA 2 Center for Liver Disease and Transplantation, Columbia University Irving Medical Center, New York, USA The first successful human liver transplant was performed by Thomas Starzl in 1967. Over subsequent decades, the field of liver transplantation has grown exponentially, mainly owing to advances in surgical technique and immunosuppression as well as improved management of complications and postoperative infections. Today, liver transplantation is considered to be a life‐saving treatment option for patients suffering from a wide variety of liver diseases (Table 61.1). According to data from the Organ Procurement and Transplantation Network, there were over 8000 deceased donor liver transplants and over 300 living donor living transplants performed in the United States in 2017 (Figure 61.1). Based on the most recent data, the unadjusted survival after transplant was 91.8% at 1 year, 83.8% at 3 years, and 76.1% at 5 years. Although the outcomes for liver transplantation continue to improve, the field is limited by the availability of donor organs. Every year, thousands of potential recipients die while on the waiting list due to lack of available donor organs. In 2017, approximately 1231 patients died while waiting for a donor organ and 1304 patients were removed from the list after being deemed too sick to transplant. In order to alleviate waitlist dropout, there has been increasing use of extended criteria donor (ECD) organs and living donor organs. These options allow some waitlist candidates to have access to an organ despite a limited supply of ideal deceased donor grafts. ECD organs are those that confer some additional risk to the recipient such as a risk of illness transmission or risk of inferior initial or long‐term function (Table 61.2). Living donor liver transplantation emerged in the early 1990s and offers several benefits to the recipient including access to an organ earlier in their disease course, freedom from the waitlist, an “elective” transplant with reduced ischemic time to the organ, and a potential healthier organ from a well‐evaluated donor. Outcomes of those undergoing living donor transplants are equal to slightly improved over those undergoing deceased donor transplants. Prior to 2002, organs were allocated based on the Child–Turcotte–Pugh (CTP) score. The CTP score incorporates serum bilirubin, albumin and elevation in prothrombin time (PT) above control values, the presence of hepatic encephalopathy and ascites. One to three points are assigned for each degree of variation amongst these parameters to yield a composite score. A patient is then classified as class A (5–6 points), B (7–9 points), or C (10–15 points). With progressive disease, CTP score increases, denoting worse survival (Table 61.3). In February 2002, the Model for End‐Stage Liver Disease (MELD) score was adopted as the score by which patients are ranked on the transplant waiting list. The MELD score is a mathematically derived score that incorporates three biochemical markers of hepatic function: the serum bilirubin, international normalized ratio (INR), and creatinine (Figure 61.2). With worsening hepatic function, the components of the score increase, resulting in a higher MELD score and denoting increasing severity of liver disease. Using the MELD allocation schema, those with the highest scores are prioritized for transplant and receive organs first regardless of competing factors such as etiology of liver disease or list waiting time. Certain disease states are poorly represented by the MELD score and many of those cases are given MELD “exception points” in order to accurately estimate disease mortality and prioritize those affected for transplant (Table 61.4). Prioritization and allocation have continued to evolve over time with the addition of hyponatremia to MELD as MELD‐Na to prioritize those with truly refractory ascites and now broader acuity circles for organ distribution to the highest lab MELD‐Na candidates. A variety of disease conditions serve as indications for liver transplantation (see Table 61.1). The goal of the liver transplant evaluation is to identify patients who will most benefit from transplant and have the best chance for long‐term survival. The evaluation process is multidisciplinary and involves thorough medical, psychiatric, social, and financial screening (Figure 61.3, Table 61.5). The transplant evaluation serves to identify modifiable complications of liver disease, evaluate conditions that may impact the outcome of the transplant, and assess for potential contraindications to the procedure (Table 61.6). Once the requisite consultations and testing are completed, a committee usually composed of transplant hepatologists, transplant surgeons, transplant coordinators, psychiatrists, social workers, and others convenes to determine appropriateness of listing. Once it is decided that a patient is an acceptable candidate for transplant, they are placed on the national United Network for Organ Sharing (UNOS) waiting list. Table 61.1 Indications for liver transplantation. Source: Based on Murray KF, Carithers RLJ. AASLD practice guidelines: evaluation of the patient for liver transplantation. Hepatology 2005;41:1407–32.
CHAPTER 61
Liver transplantation
Organ allocation
Transplant indications, contraindications, and evaluation
Autoimmune liver disease
Alcohol‐associated liver disease
Nonalcohol‐associated fatty liver disease
Inherited/metabolic liver diseases
Hereditary hemochromatosis
α1‐antitrypsin deficiency
Wilson disease
Tyrosinemia
Type IV glycogen storage disease
Neonatal hemochromatosis
Amyloidosis
Hyperoxaluria
Urea cycle defects
Amino acid defects
Chronic viral liver disease
Hepatitis C
Hepatitis B
Hepatitis D
Cholestatic liver disease
Primary biliary cholangitis
Primary sclerosing cholangitis
Biliary atresia
Alagille syndrome
Progressive familial intrahepatic cholestasis
Cystic fibrosis Related posts:
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