What are the criteria for evaluating patients with liver cirrhosis for a liver transplant?

Criteria for Evaluation for Liver Transplantation in Patients with Liver Cirrhosis

Patients with cirrhosis should be referred for liver transplantation when they develop evidence of hepatic dysfunction (Child-Turcotte-Pugh score > 7 and MELD score > 10) or when they experience their first major complication (ascites, variceal bleeding, or hepatic encephalopathy). 1

Primary Evaluation Criteria

Disease Severity Assessment

1. Child-Turcotte-Pugh (CTP) Score

   • Class A (5-6 points): 90% 5-year survival without transplant
   • Class B (7-9 points): 80% 5-year survival without transplant
   • Class C (10-15 points): >33% will die within 1 year without transplant 1

   Parameter	1 point	2 points	3 points
   Encephalopathy	None	Grade 1-2	Grade 3-4
   Ascites	Absent	Slight	Moderate
   Bilirubin (mg/dL)	1-2	2-3	>3
   Albumin (g/dL)	>3.5	2.8-3.5	<2.8
   INR	<1.7	1.7-2.3	>2.3

2. Model for End-Stage Liver Disease (MELD) Score

   • Calculated using bilirubin, INR, and creatinine
   • Scale from 6-40, correlating with 3-month mortality (90% to 7% survival)
   • MELD ≥15 is a key threshold for transplant evaluation 2

Complications of Cirrhosis

Presence of any of these complications significantly worsens prognosis and should prompt transplant evaluation:

1. Ascites - median survival 1.1 years after onset 3
2. Variceal bleeding - indicates significant portal hypertension
3. Hepatic encephalopathy - median survival 0.92 years after onset 3
4. Spontaneous bacterial peritonitis - <50% 1-year survival 1
5. Hepatorenal syndrome - median survival <2 weeks for type I 1

Special Considerations

Hepatocellular Carcinoma (HCC)

• Small HCCs complicating cirrhosis are indications for transplantation 1
• Criteria for transplantation:
  • Tumors ≤5 cm or ≤3 in number
  • No extrahepatic disease (absolute contraindication)
  • Fibrolamellar variant has different size criteria 1

Alcoholic Liver Disease

• Selected patients with advanced alcoholic liver disease can benefit from transplantation 1
• Six-month supervised abstinence is desirable but not mandatory 1
• Psychosocial assessment by multidisciplinary team is essential 1
• Differentiate alcohol dependence from non-dependent misuse 1

Viral Hepatitis

• Patients with end-stage HBV must be HBV DNA negative before transplantation
• Antiviral treatment can render HBV DNA positive patients eligible 1

Acute-on-Chronic Liver Failure (ACLF)

• Evolution of organ failures during ICU stay is crucial for prognosis
• SOFA score >10 predicts 93% mortality 1
• Persistence of 3-4 non-hematological organ failures at day 3 predicts poor outcome 1
• Early transplantation can improve survival to 78% at one year compared to <10% without transplant 1

Transplant Evaluation Process

1. Medical Assessment

   • History and physical examination
   • Laboratory studies to confirm etiology and severity of liver disease
   • Creatinine clearance
   • Viral serology (HBV, HCV, EBV, CMV, HIV)
   • Abdominal imaging for vascular anatomy and HCC screening 1

2. Cardiopulmonary Assessment

   • Echocardiography
   • Pulmonary function tests
   • Stress testing for patients >50, smokers, or with cardiac risk factors 1
   • Right heart catheterization if pulmonary hypertension suspected 1

3. Psychosocial Evaluation

   • Compliance assessment
   • Substance abuse history
   • Support system evaluation
   • Psychiatric assessment 1

Contraindications and Cautions

1. Absolute Contraindications

   • Uncontrolled extrahepatic malignancy
   • Uncontrolled sepsis
   • Severe cardiopulmonary disease
   • Inability to comply with post-transplant regimen 1

2. Relative Contraindications

   • Morbid obesity (BMI >40 kg/m²) - associated with decreased survival 1
   • Advanced age - not a specific limitation but associated with higher mortality from malignancies 1
   • Severe pulmonary hypertension - unless controllable with medical therapy 1

Common Pitfalls in Transplant Evaluation

1. Delayed Referral - Patients should be referred early when CTP >7 and MELD >10, not waiting until severe decompensation occurs 1

2. Overlooking Complications - The presence of complications (ascites, encephalopathy, variceal bleeding) indicates poor prognosis even with relatively low MELD scores 4

3. Inadequate Cardiac Evaluation - Cardiovascular disease is a major cause of perioperative mortality 1

4. Neglecting Alternative Treatments - All disease-specific treatments should be considered before committing to transplantation 1

5. Focusing Only on MELD Score - Patients with cirrhosis-related complications may have poor outcomes despite relatively low MELD scores 4

By systematically evaluating these criteria, clinicians can identify appropriate candidates for liver transplantation and optimize timing of referral to improve survival outcomes.