Overview

1. Liver transplantation has a major survival benefit in patients with end-stage liver disease (ESLD) who would otherwise have a high short-term mortality rate.

2. More than 16,000 patients are currently listed for liver transplantation in the United States, and approximately 6000 persons undergo liver transplantation annually.

The number of patients on the transplant waiting list remained stable during the late 2000s.

Approximately 2000 patients die every year while awaiting liver transplantation.

3. Advances in surgical techniques and post-transplant care have led to improved long-term survival of liver transplant recipients.

Overall adjusted survival rates following deceased donor liver transplantation is approximately 87% at 1 year, 73% at 5 years, and 59% at 10 years.

Survival among transplant recipients varies based on the pretransplant diagnosis.

The 5-year survival rates following transplantation are greatest in patients with cholestatic liver disease or metabolic disorders, whereas patients with noncholestatic liver diseases such as chronic viral hepatitis, alcoholic liver disease, and autoimmune hepatitis have lower survival rates.

Selection of Candidates

Indications for liver transplantation

1. Liver transplantation should be considered in patients with irreversible liver failure resulting from acute or chronic liver diseases, as well as hepatocellular malignant diseases (Table 31.1).

2. All forms of effective therapy should be explored before liver transplantation.

3. The severity of liver disease and the potential benefit of liver transplantation are important considerations in evaluating a patient’s candidacy for transplantation.

table 31.1 Indications for liver transplantation in adults

Category	Disease
Noncholestatic or inflammatory	Chronic hepatitis C Chronic hepatitis B Alcoholic liver disease Autoimmune hepatitis Cryptogenic cirrhosis Nonalcoholic fatty liver disease Drug-induced liver injury Sarcoidosis
Cholestatic	Primary biliary cirrhosis Primary sclerosing cholangitis Secondary biliary cirrhosis Idiopathic adulthood ductopenia Cystic fibrosis Familial intrahepatic cholestasis syndromes
Metabolic	Alpha-1 antitrypsin deficiency Hereditary hemochromatosis Wilson disease Glycogen storage disease
Malignant	Hepatocellular carcinoma Neuroendocrine tumors Epithelioid hemangioendothelioma Fibrolamellar hepatocellular carcinoma
Extrahepatic	Familial amyloidosis Primary hyperoxaluria Homozygous familial hypercholesterolemia
Miscellaneous	Acute liver failure Budd–Chiari syndrome Polycystic liver disease Giant cavernous hemangioma Noncirrhotic portal hypertension Retransplantation

Assessment of liver disease severity

An accurate assessment of the risk of morbidity and mortality associated with progressive ESLD is critical to determining the appropriate timing for referral to a liver transplant center and is a key factor in prioritization for transplantation.

1. Child–Turcotte–Pugh (CTP) score (Table 31.2)

This score was developed to predict operative mortality in persons with cirrhosis who required portacaval shunt surgery for variceal bleeding.

Child–Pugh classes B and C are associated with a survival benefit following liver transplantation.

This score was previously used for allocation of donor organs and is still widely used to predict the risk of perioperative mortality in cirrhotic patients undergoing surgery (see Chapter 30).

2. Model for End-stage Liver Disease (MELD)

The MELD was initially developed to predict 3-month mortality in patients undergoing transjugular intrahepatic portosystemic shunt (TIPS) placement.

The components—serum creatinine and total bilirubin levels and the international normalized ratio (INR) of prothrombin time—are key determinants of survival (Table 31.3).

It is superior to the CTP score in predicting short-term (3-month) mortality in patients with ESLD.

It was introduced in 2002 as the basis for allocation of donor organs in the United States.

3. The Baveno IV consensus workshop identified four clinical stages of ESLD, based on the development of complications, each of which may predict mortality (Table 31.4). The risk of clinical decompensation and progression from compensated ESLD to a more advanced stage is approximately 10% per year.

TABLE 31.2 Child–Turcotte–Pugh scoring system and Child–Pugh Classification

TABLE 31.3 Model for End-stage Liver Disease

MELD score = 9.57 × log_e (serum creatinine [mg/dL]) + 3.78 × log_e (serum bilirubin [mg/dL]) + 11.20 × log_e (INR) + 6.43

INR, international normalized ratio; MELD, Model for End-stage Liver Disease.

Adapted from Wiesner R, Edwards E, Freeman R, et al. Model for End-stage Liver Disease (MELD) and allocation of donor livers. Gastroenterology 2003; 124:91–96.

TABLE 31.4 Clinical stages of cirrhosis and mortality risk

Stage	Complications	1-yr mortality risk (%)
1	No varices No ascites	1
2	Varices present No ascites	3.4
3	Ascites present	20
4	Variceal hemorrhage	57

Adapted from D’Amico G, Garcia-Tsao G, Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies. J Hepatol 2006; 44:217–231.