Indications and contraindications for liver transplantation

By Alex Yartsev - 30/06/2015
Last updated 30/06/2015 - 17:49
 Topic: Gastroenterology and Hepatology

Surprisingly, having somebody else's major abdominal organ is well tolerated. The one year survival for these people is in excess of 90%.

Criteria for liver transplantation

TSANZ (The Transplantation Society of Australia and New Zealand) has an online liver protocol (last updated in 2007) which renders transparent the complex process of recipient selection.

General criteria for transplant listing

  • "life threatening acute or chronic liver disease not amenable to alternative therapy"
  • "extrahepatic manifestations of inborn error of metabolism"
  • Transplantation is to improve life expectancy (i.e. not "palliative" transplantation)
  • No absolute contraindications

Criteria for acute "urgent" listing

The most commonly used criteria for transplantation in the acute settings are the King's College criteria, for all their flaws.

Contraindications to liver transplantation

According to Oh's Manual,

"Listing requires a multidisciplinary consensus of a 50% chance of 5-year survival once all risks are considered."

 

The MELD score is used to assess the urgency of transplantation as well as the likelihood of post-transplant survival. The other single most important parameter is cardiovascular health - one must be fit enough to survive the procedure. Cardiovascular complications are the most important extrahepatic cause of death in the liver transplant recipient.

Thus, there are several absolute contraindications:

Absolute contraindications to liver transplantation:

  • Active sepsis
  • Extrahepatic malignancy
  • Severe cardiac disease
  • Severe respiratory disease
  • Ongoing alcohol or IV drug use
  • Confirmed AIDS
  • Poor compliance: "inability to co-operate with life long medical supervision"
  • Severe neurological or developmental impairment

Then, there are also a few relative contraindications:

Relative contraindications to liver transplantation:

  • Renal failure
  • Extensive upper GI or biliary surgery
  • Confirmed HIV (it should be fully suppressed with HAART)
  • Social problems leading to poor compliance

References

Chapter 101  (pp. 1040)  Liver  transplantation by Anish  Gupta,  Simon  Cottam  and  Julia  Wendon

Roberts, Mark S., et al. "Survival after liver transplantation in the United States: a disease‐specific analysis of the UNOS database." Liver transplantation 10.7 (2004): 886-897.

Onaca, Nicholas N., et al. "A correlation between the pretransplantation MELD score and mortality in the first two years after liver transplantation." Liver transplantation 9.2 (2003): 117-123.

Vaid, Arjun, et al. "Molecular adsorbent recirculating system as artificial support therapy for liver failure: a meta-analysis." ASAIO Journal 58.1 (2012): 51-59.

Bañares, Rafael, et al. "Extracorporeal albumin dialysis with the molecular adsorbent recirculating system in acute‐on‐chronic liver failure: The RELIEF trial." Hepatology 57.3 (2013): 1153-1162.

Schroeder, Rebecca A., et al. "Intraoperative fluid management during orthotopic liver transplantation." Journal of cardiothoracic and vascular anesthesia 18.4 (2004): 438-441.

Kirby, R. M., et al. "Orthotopic liver transplantation: postoperative complications and their management." British journal of surgery 74.1 (1987): 3-11.

Hannaman, Michael J., and Zoltan G. Hevesi. "Anesthesia care for liver transplantation."  Transplantation Reviews 25.1 (2011): 36-43.

Moreno, Rosalba, and Marina Berenguer. "Post-liver transplantation medical complications."  Ann Hepatol 5.2 (2006): 77-85.

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