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Liver Transplant (LT) Workup

Katelyn Backhaus

Background

  • Model for End-stage Liver Disease (MELD-Na) score: initially developed to predict survivalfollowing TIPS placement, though is now used to objectively rank patients in terms of priority for liver transplant (LT)
    • Factors in total bilirubin, creatinine, INR, and Na.
    • 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
    • Highest score lasts for 7 days
  • 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

  • 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:

    • If RVSP > 40mmHg on TTE, then R Heart Catheterization is indicated

  • PFT’s, carotid US

  • Panorex to identify dental disease; consult OMFS pending results

  • Appropriate cancer screenings (CXR in all patients, CT Chest in prior/current smokers, colonoscopy, pap smear, mammogram, and PSA if applicable)

  • DEXA scan (osteoporosis in up to 55% of individuals with cirrhosis)

  • 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 for no less than 3-6 months, although exceptions may be made for early liver transplant based on a very strict protocol. Discuss exception criteria with attending if suspect patient unlikely to survive hospitalization without transplant

  • Both living and deceased donor transplants are offered at VUMC. Donor evaluation, however, cannot be started before the potential recipient is deemed a candidate. Of note, should consider possible simultaneous liver-kidney transplantation for 1) CKD <30mL/min after > 90 days of eGFR<60 or 2) AKI dependent on dialysis >8 weeks or if extensive glomerulosclerosis present.