What is involved in a liver transplant workup?

Liver Transplant Workup: A Comprehensive Evaluation Protocol

A liver transplant workup requires a thorough multidisciplinary assessment including medical, surgical, and psychosocial evaluations to determine candidacy and optimize outcomes for patients with end-stage liver disease.

Initial Assessment and Indications

The evaluation begins with determining if the patient is sick enough to require transplantation and that no alternative treatments are available. Key components include:

• Confirming the diagnosis and severity of liver disease
• Evaluating disease-specific treatments that might avoid transplantation 1
• Assessing the patient's ability to survive the operation and comply with post-transplant care 1
• Identifying comorbidities that could compromise graft or patient survival 1

Core Components of Liver Transplant Workup

Medical Evaluation

1. Comprehensive history and physical examination 1

2. Laboratory studies:

   • Liver function tests to confirm etiology and severity of liver disease
   • Creatinine clearance assessment
   • Viral serology (HBV, HCV, EBV, CMV, HIV) 1
   • MELD score calculation for prioritization 2

3. Cardiopulmonary assessment:

   • Cardiac echocardiography
   • Pulmonary function tests
   • Dobutamine stress testing (for patients >50 years, smokers, or with history of heart disease/diabetes) 1
   • Cardiac catheterization for positive stress tests 1
   • Evaluation for pulmonary hypertension (mean pressure >35 mm Hg is a contraindication) 1

4. Abdominal imaging:

   • CT scan or MRI to evaluate:
     • Hepatic artery and portal vein anatomy
     • Presence of hepatocellular carcinoma
     • Integrity of splanchnic blood supply 1
     • Portal vein thrombosis (a potential contraindication) 1

5. Bone health assessment:

   • Bone densitometry to evaluate for osteoporosis 1
   • Prevention of pathological fractures in the perioperative period 1

6. Nutritional assessment:

   • Evaluation of malnutrition and sarcopenia
   • CT scan assessment of psoas muscle thickness 1
   • Management of patients with BMI extremes (≥40 or <18.5) 1

7. Renal function evaluation:

   • Assessment for hepatorenal syndrome
   • Consideration for combined liver-kidney transplant if GFR <30 ml/min or requiring dialysis >8-12 weeks 1

Surgical Evaluation

1. Vascular assessment:

   • Evaluation of portal vein patency
   • Assessment of splanchnic venous inflow system 1
   • CT or MR angiography to evaluate hepatic arterial anomalies 1

2. Technical feasibility assessment:

   • Identification of surgical contraindications (e.g., absence of viable splanchnic venous inflow) 1
   • Planning for potential surgical challenges 3

Psychosocial Evaluation

1. Substance abuse assessment:

   • Evaluation of alcohol use history
   • Supervised abstinence period assessment 2

2. Psychiatric evaluation:

   • Assessment of compliance potential
   • Evaluation of support systems 4

3. Social support assessment:

   • Identification of caregivers
   • Evaluation of post-transplant care plan 4

Special Considerations

Metabolic Dysfunction-Associated Steatotic Liver Disease (MASLD)

• Cardiovascular risk assessment using a stepwise approach 1
• Weight reduction interventions before transplantation 1
• Target BMI <40 kg/m² and ideally <35 kg/m² 1

HIV Infection

• Not an absolute contraindication with well-controlled disease on HAART 1
• Requires multidisciplinary team with expertise in both transplantation and HIV management 1

Hepatic Encephalopathy

• Neurological workup to exclude differential diagnoses 1
• Consideration for expedited transplantation in patients with disabling symptoms refractory to treatment 1

Contraindications

Absolute Contraindications

• Extrahepatic malignancy
• Advanced AIDS
• Severe cardiorespiratory disease 1
• Active infections (must be resolved before transplantation) 2

Relative Contraindications

• Severe pulmonary hypertension (mean pressure >35 mm Hg) 1
• Complete portal vein thrombosis or cavernous transformation 1
• Morbid obesity (BMI >40) without weight loss plan 1

Common Pitfalls and Caveats

• Portal vein assessment: Failure to identify portal vein thrombosis can lead to increased perioperative mortality and graft loss 1
• Cardiac evaluation: Underestimating coronary artery disease risk can lead to high perioperative mortality 1
• Renal function: Inaccurate assessment may lead to missed opportunity for combined liver-kidney transplant 1
• Nutritional status: Both malnutrition and morbid obesity increase post-transplant mortality 1
• Bone health: Failure to address osteoporosis can lead to pathological fractures post-transplant 1

By following this comprehensive evaluation protocol, transplant teams can optimize candidate selection, improve perioperative outcomes, and enhance long-term survival after liver transplantation.