Liver Transplantation

Top tips:

  1. Referral to a Transplant Hepatologist should be considered for patients with decompensated cirrhosis, MELD-Na >15, or primary intrahepatic malignancies (hepatocellular cancer).
  2. There are many patient-related factors that can adversely affect patient outcomes. These factors can constitute relative or absolute contraindications to transplantation.
  3. Many transplant programs have made changes to criteria for transplantation in the setting of alcohol-related liver disease (including Alberta). An exception pathway may be available for highly selected individuals who may not have met 6 month abstinence criteria.
  4. Total tumor volume (TTV) and alpha-fetoprotein (AFP) are used to guide liver transplantation eligibility for hepatocellular carcinoma.

General Cirrhosis Admission and Discharge Order Sets

*Add specific panels to general admission orders as appropriate*

For adults with cirrhosis requiring hospital admission
Cirrhosis Adult Admission Orders

For adults with cirrhosis requiring hospital discharge
Cirrhosis Adult Discharge Orders

Check out the bottom of the page for short videos from Dr. Sadler!

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
    • 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

Introducing Dr. Sadler

Video 1 – The top tips that may be useful for you to know about this page as a family physician including: What does the transplant team consider when they are considering eligibility for transplantation? Working together to support the patients on the list AND When you should call a specialist to discuss whether your patient with alcohol related liver disease may be a candidate for transplantation.

Coming soon!

Patient materials:

You can direct patients to the following:
Liver transplant

Lab tests

Calculators:

Use these calculators:

Total Tumour Volume Calculation

References:

This section was adapted from content using the following evidence based resources in combination with expert consensus. The presented information is not intended to replace the independent medical or professional judgment of physicians or other health care providers in the context of individual clinical circumstances to determine a patient’s care.

Authors: Dr. Vince Bain, Dr. Matt Sadler, Dr. Rahima Bhanji, Dr. Puneeta Tandon

References:

  1. Adult Liver Transplant Management Guidelines 2016, Version 2.0
  2. Evaluation for Liver Transplantation in Adults: 2013 Practice Guideline by the American Association for the Study of Liver Disease and the American Society of Transplantation. Hepatology 2014 PMID 24716201
guest

We would really appreciate your feedback to make this page better. Thanks for taking the time to do this!

How would you best describe yourself?
I found this webpage useful
The content on this page is easy to navigate
I found what I was looking for on the page
0 Comments
Inline Feedbacks
View all comments