What criteria are used to select a patient for liver transplantation?

Selection Criteria for Liver Transplantation

Liver transplantation candidates should be selected based on disease severity, calculated prognosis, quality of life considerations, and the absence of contraindications that would compromise post-transplant outcomes. 1, 2

Medical Evaluation Criteria

End-Stage Liver Disease

• Patients with end-stage liver disease should be referred when:
  • Expected survival without transplantation is one year or less
  • Major complications of cirrhosis have occurred:
    • Variceal hemorrhage
    • Ascites
    • Hepatorenal syndrome
    • Hepatic encephalopathy 1

Acute Liver Failure

• Represents an urgent indication for transplantation
• Common causes: viral hepatitis (A and B), drugs (acetaminophen), toxic agents
• Prognosis determined primarily by neurological status 1

Hepatocellular Carcinoma (HCC)

• Milan Criteria (optimal outcomes):
  • Single lesion ≥2 cm and <5 cm, OR
  • Up to three lesions with largest <3 cm
  • No radiographic evidence of extrahepatic disease 1, 2
• Patients meeting these criteria should receive a donor organ within 6 months of listing 1

Metabolic Diseases

• Indicated for metabolic diseases causing progressive extra-hepatic injury
• Must be unresponsive to disease-specific interventions
• Transplantation should result in reversal of enzyme deficiency 1

Contraindications

Absolute Contraindications

• Metastatic cancer
• Uncontrolled sepsis
• Irreversible cerebral edema with uncal herniation
• Cholangiocarcinoma (except in research protocols)
• Alpha-fetoprotein levels >1,000 ng/ml (regardless of tumor burden) 2
• Active malignancy (except selected indolent or very low-grade cancers) 1

Relative Contraindications

• Coronary artery disease (requires thorough evaluation)
• Severe hypoxia (PaO2 ≤50 mmHg) in hepatopulmonary syndrome 1

Psychosocial Evaluation

The psychosocial evaluation is essential for identifying factors that may affect post-transplant outcomes:

• Compliance with medical regimen 1, 3
• Social support system adequacy 4, 5
• Substance abuse history and risk of relapse 1, 5
• Psychological stability and coping mechanisms 6, 7

Specific Psychosocial Criteria

• Ability to comply with complex post-transplant medical regimen
• Strong social and family support
• For alcohol-related liver disease:
  • Evidence of insight into alcohol use disorder
  • Ability to maintain therapeutic relationship with transplant team 5
  • In severe alcoholic hepatitis cases, fast-track transplantation may be considered with rigorous selection process 1

Transplant Center Evaluation Process

A comprehensive evaluation at transplant centers typically includes:

1. Detailed history and physical examination
2. Cardiopulmonary assessment:
   • Cardiac echocardiography
   • Pulmonary function tests
   • Dobutamine stress testing (for patients >50, smokers, or with history of heart disease/diabetes)
   • Cardiac catheterization for positive stress tests
3. Laboratory studies:
   • Etiology and severity of liver disease
   • Creatinine clearance
   • Viral status (HBV, HCV, EBV, CMV, HIV)
4. Abdominal imaging to determine:
   • Hepatic artery and portal vein anatomy
   • Presence of hepatocellular carcinoma 1

Special Considerations

Age

• No specific age limitation exists
• Older patients have diminished long-term survival primarily due to increased risk of death from malignancies 1

Previous Malignancy

• Patients with history of recently treated non-hepatic cancer require:
  • Multidisciplinary assessment
  • Detailed cancer- and treatment-specific information
  • "Recurrence-free survival" estimates
  • Evaluation of therapeutic options for potential post-LT cancer recurrence 1

Neurological Wilson's Disease

• Patients with neurological symptoms should be evaluated by transplant specialists in conjunction with neurologists
• Decision should consider possible irreversibility of neurological damage 1

The selection process must balance the ethical allocation of scarce donor organs with the goal of maximizing post-transplant survival and quality of life. Early referral to transplant centers is crucial to optimize outcomes.