What are the criteria for a liver transplant in patients with end-stage liver disease?

Criteria for Liver Transplantation in End-Stage Liver Disease

Patients with end-stage liver disease should be referred for liver transplantation evaluation when they develop evidence of hepatic dysfunction (MELD >10) or experience their first major complication (ascites, variceal bleeding, or hepatic encephalopathy), with a MELD score ≥15 generally recommended as the minimum threshold for listing. 1

Primary Indications for Liver Transplantation

Chronic Liver Disease

• MELD Score ≥15: Corresponds to a 5-year transplant benefit of 12 months of life gain 2
• Child-Turcotte-Pugh (CTP) Class C (score ≥10): Associated with >30% one-year mortality without transplantation 2
• Major complications of cirrhosis:
  • Refractory ascites
  • Hepatic encephalopathy
  • Variceal bleeding
  • Spontaneous bacterial peritonitis
  • Hepatorenal syndrome (especially type I with median survival <2 weeks) 2

Disease-Specific Indications

Viral Hepatitis

• Hepatitis B: Patients must be HBV DNA negative before transplantation (can be achieved with antiviral treatment) 2
• Hepatitis C: Advanced cirrhosis with complications 2

Alcoholic Liver Disease

• Advanced alcoholic liver disease with poor prognosis 2
• Abstinence requirements: Six-month period of supervised community abstinence is desirable but not mandatory 2
• Special considerations for young patients: Less stringent evaluation may be appropriate for life-threatening presentations 2

Autoimmune Hepatitis

• Failure to achieve biochemical remission
• Shrinking liver volume
• Severe acute presentation
• Progressive decompensation in chronic cases 2

Hepatocellular Carcinoma (HCC)

• Small HCC complicating cirrhosis: Recommended for transplantation 2
• Size limitations: Tumors >5 cm or more than three in number require novel management strategies 2
• Contraindications: Local or systemic extrahepatic HCC disease 2
• Exception: Fibrolamellar variant not constrained by size/volume criteria 2

Acute Liver Failure

• Paracetamol hepatotoxicity: Based on specific guidelines for referral 2
• Non-paracetamol acute and subacute liver failure: Presence of encephalopathy (including fulminant Wilson's disease) 2
• Progressive coagulopathy: Even in absence of encephalopathy, should be discussed with transplant center 2

Contraindications

Absolute Contraindications

• Malignancy: Active extrahepatic malignancy (except for neuroendocrine tumors) 2
• Cholangiocarcinoma: Unless part of novel management strategy 2
• Severe comorbidities:
  • Advanced cardiac disease (NYHA class III or IV)
  • Severe pulmonary disease (GOLD criteria 3 or 4)
  • Advanced neurological disease with ACLF-3 2

Relative Contraindications

• Advanced age: Especially with physiological frailty 2
• Severe sarcopenia: With muscle wasting and malnutrition 2
• Poor functional status: Karnofsky performance status ≤40 2
• Portal venous system thrombosis: Requires specialized assessment 2
• Pulmonary hypertension: Requires assessment at transplant center 2

Prioritization Systems

MELD Score

• Calculation: Based on serum bilirubin, INR, and creatinine 1
• Interpretation:
  • MELD 6-9: 1.9% 90-day mortality
  • MELD 10-19: 6% 90-day mortality
  • MELD 20-29: 19.6% 90-day mortality
  • MELD 30-39: 52.6% 90-day mortality
  • MELD ≥40: 71.3% 90-day mortality 1

MELD Exceptions

• Hepatocellular carcinoma
• Hepatopulmonary syndrome
• Portopulmonary hypertension 1

Acute-on-Chronic Liver Failure (ACLF)

• CLIF-C ACLF score: Better predictor of 28-day mortality compared to MELD, MELD-Na, and Child-Pugh scores 2
• ICU admission criteria:
  • Need for organ support (vasopressors, mechanical ventilation, renal replacement)
  • Massive bleeding
  • Grade III-IV hepatic encephalopathy
  • Septic shock 2

Important Clinical Considerations

Timing of Referral

• Early referral: When MELD >10 or first major complication occurs 1
• Urgent referral: For acute liver failure or rapid decompensation 2

Evaluation Process

• Multidisciplinary assessment: Hepatologist, transplant surgeon, intensivist 2
• Psychosocial evaluation: Particularly important for alcoholic liver disease 2
• Comorbidity screening: Essential element of assessment 2

Pitfalls to Avoid

1. Delayed referral: Current prognostic scoring systems have acceptable specificity but low sensitivity 2
2. Overreliance on MELD alone: Does not account for complications like encephalopathy or ascites 1
3. Failure to consider transplant benefit: Should evaluate potential gain in life years and quality-adjusted life years 2
4. Inadequate viral suppression: HBV patients must achieve viral suppression before transplantation 2

Special Populations

Acute Liver Failure

• King's College Hospital criteria have high specificity but limited sensitivity 3
• MELD >30 has higher sensitivity but lower specificity for predicting outcomes 3

Hepatitis B-induced ACLF

• MELD score may not accurately predict post-transplant outcomes in these patients 4
• Antiviral therapy is essential before transplantation 2

By following these criteria and considerations, clinicians can appropriately identify and refer patients with end-stage liver disease for liver transplantation evaluation, optimizing outcomes and resource utilization.