What are the indications for liver transplantation in an adult patient with a history of liver disease, such as hepatitis C or alcoholic liver disease?

Liver Transplantation Indications in Adults

Liver transplantation should be considered for adults with end-stage liver disease from hepatitis C or alcoholic liver disease when they develop life-threatening complications (ascites, variceal bleeding, hepatic encephalopathy, hepatorenal syndrome) or reach a MELD score ≥15, as this threshold indicates transplant benefit exceeds waitlist mortality risk. 1

Primary Disease Categories Warranting Transplantation

Chronic Liver Disease Indications

• Chronic hepatitis C with decompensated cirrhosis (Child-Pugh class C or MELD-Na ≥21) requires referral for transplantation 1
• Alcoholic liver disease with decompensation is an established indication, with transplantation in selected patients improving outcomes 2
• Other chronic noncholestatic disorders including chronic hepatitis B and autoimmune hepatitis are established indications 1

MELD Score-Based Prioritization

The allocation system operates algorithmically based on disease severity:

• MELD ≥15: List for transplantation, as benefit exceeds waitlist mortality 1
• MELD 15-29: Standard priority with regional allocation 1
• MELD >30: Urgent priority with macro-area level allocation 1

Referral should occur before development of malnutrition, hepatorenal failure, and advanced disease severity to optimize outcomes 1

Disease-Specific Considerations

Hepatitis C

• End-stage liver disease from hepatitis C with any hepatic decompensation warrants transplant evaluation 1
• Early referral at first decompensation event facilitates optimal timing 1

Alcoholic Liver Disease

The critical algorithmic approach for ALD:

1. Assess disease severity: Decompensated cirrhosis with Child-Pugh class C or MELD-Na ≥21 requires referral 1

2. Abstinence evaluation: A 6-month period of supervised community abstinence is desirable but not mandatory 2, 1

   • Selection should not be based solely on fixed abstinence intervals 1, 3
   • Comprehensive evaluation of recidivism risk factors is more predictive than duration alone 3

3. Multidisciplinary assessment requirements:

   • Psychosocial assessment by transplant team including addiction specialist 2, 1
   • Differentiate alcohol dependence from non-dependent misuse 2
   • Exclude significant comorbid disease 2

4. Special circumstances: Young patients on first medical presentation with life-threatening illness may not need stringent evaluation 2

Common pitfall: The strict 6-month rule may unfairly penalize low-risk patients unlikely to survive the waiting period 3. Active alcohol use is a relative contraindication, not absolute 2, 3.

Hepatocellular Carcinoma Complicating Cirrhosis

• Small HCC meeting Milan criteria (single tumor ≤5 cm or ≤3 tumors each ≤3 cm) should receive transplantation, providing 75% 4-year survival with 83% recurrence-free survival 2, 1
• Tumors >5 cm or >3 in number should only be assessed with novel management strategies 2
• Extrahepatic HCC is an absolute contraindication 2, 1

Acute Liver Failure

• All patients with non-paracetamol acute/subacute liver failure with encephalopathy (including fulminant Wilson's disease) must be referred to a transplant center 2, 1
• Paracetamol hepatotoxicity meeting specific criteria requires specialist referral 2, 1
• Progressive coagulopathy without encephalopathy warrants discussion with transplant center 2

Absolute Contraindications (Preclude Transplantation)

The following conditions make transplantation impossible:

• AIDS 2, 1
• Extrahepatic malignancy (except neuroendocrine tumors and hemangioendothelioma in some centers) 2, 1
• Advanced cardiopulmonary disease 2, 1
• Cholangiocarcinoma (unless experimental protocol) 2, 1
• Limited life expectancy from non-liver-related comorbidities 1

Relative Contraindications (Weigh Against but Not Absolute)

• HIV positivity 2, 1
• Age above 70 years 2, 1
• Significant sepsis outside biliary tree 2, 1
• Active alcohol/substance misuse (emphasis on "active") 2, 1, 3
• Severe psychiatric disorder 2, 1
• Portal venous system thrombosis (requires transplant center assessment) 2, 1
• Pulmonary hypertension (requires transplant center assessment) 2, 1

Mandatory Evaluation Components

Before listing, patients must undergo:

• Multidisciplinary assessment involving transplant hepatologist, transplant surgeon, and specialists 1
• Evaluation of comorbidities compromising post-transplant outcomes 1
• Assessment of ability to comply with complex medical regimens 1
• Exclusion of significant comorbid disease 2, 1

Critical timing consideration: The evaluation process itself takes time, so beginning evaluation does not mean immediate listing or transplantation 3