Liver Transplantation

Liver transplantation (LT) is an accepted therapeutic modality for:

• End-stage liver disease (acute or chronic); and
• Selected tumors

Transplantation is indicated for patients with advanced forms of disease in whom no realistic hope for extension of life exists with other forms of medical or surgical intervention. In general, for patients with cirrhosis, one should consider referral for liver transplantation as they develop features of decompensated liver disease such as ascites, bleeding esophageal or gastric varices and hepatic encephalopathy that are not easily controlled with medical/endoscopic therapy.  The MELD-sodium is also a general guide.  Most patients who are considered for transplant have MELD-sodium values >15, but there are certainly exceptions whereby patients with lower MELD scores can be considered. This links to the OPTN (Organ Procurement and Transplantation Network) MELD exception document from 2017.

Indications for Liver Transplantation:

1. Hepatocellular Liver Disease
   • Nonalcoholic Steatohepatitis
   • Viral Hepatitis
   • Alcohol related Cirrhosis with 6 months abstinence from alcohol.
   • • Selected patients may meet criteria for the new exception pathway. Consult Transplant hepatology to discuss these cases.
   • Severe Alcoholic Hepatitis refractory to steroids
     • Selected patients may meet criteria for the new exception pathway. One of the requirements is that there can be no prior history of hospital or ER visits with intoxication or alcohol withdrawal. There are a list of other criteria. Consult Transplant hepatology to discuss these cases.
   • Hepatitis B
   • Cryptogenic Cirrhosis
2. Cholestatic Liver Disease
   • Primary Biliary Cholangitis, Primary Sclerosing Cholangitis, Secondary Biliary Cirrhosis, Idiopathic or Drug Induced Cholestasis
3. Inborn Errors of Metabolism
   • Wilson’s Disease, Alpha 1 Antitrypsin Deficiency, Hemochromatosis, Familial Amyloidosis Polyneuropathy, Other
4. Fulminant Hepatic Failure
5. Budd-Chiari Syndrome
6. Drug Toxicity leading to liver failure
7. Other
8. Selected intrahepatic malignancies – this refers to tumors originating within the liver, not metastatic disease to the liver. Involve a liver specialist with any suspected diagnosis of Hepatocellular carcinoma (HCC).
   • Listing criteria for Hepatocellular carcinoma
     • Total tumor volume (TTV) is ≤115 cm³ AND AFP ≤400 ug/mL
   • Not candidates for transplant
     • TTV >115 cm³ OR AFP >400 ug/mL
     • Metastasis outside the liver
     • HCC vascular invasion on radiological imaging
     • General contraindications for liver transplantation
   • Useful HCC information – see HCC page for more HCC details
     • TTV is calculated based on the area of any viable tumor (tumor showing enhancement).
     • Under the guidance of a liver specialist, a patient can be considered for HCC down-staging if TTV ≤250 cm³, regardless of AFP. Following down-staging, a patient can be considered for transplantation if TTV ≤115cm³ AND AFP ≤400 ng/mL for 6 months.
   • TTV calculator

Contraindications for Liver Transplantation

During the evolution of clinical transplantation internationally, and at University of Alberta Hospital, multiple patient-related factors have come to be recognized as adversely affecting patient outcome.   These factors constitute relative or absolute contraindications to transplantation.

The following factors exert a major adverse influence on the outcome of transplantation and would be absolute contraindications in most cases:

Absolute Contraindications

• Active systemic sepsis
• Systemic disease such as metastatic cancer, AIDS, mitochondrial disorders
• pneumonia, unresolved pulmonary infarction or other pulmonary infiltrates
• Severe non-correctable peripheral or cerebrovascular disease
• Severe irreversible cardiac disease (unless simultaneous liver and heart transplantation considered)
• Advanced cardiopulmonary disease
• Clear history of non-compliance
• Active alcohol or drug abuse (note: alcohol exception pathway criteria detailed above)
• Uncontrolled psychiatric disease
• Severe neurological instability or advanced neurological illness
• BMI > 45
• Age > 75 years