Liver transplantation or hepatic transplantation is the replacement of a diseased liver with the healthy liver from another person (allograft). Liver transplantation is a treatment option for end-stage liver disease and acute liver failure, although the availability of donor organs is a major limitation. Liver transplantation is highly regulated and only performed at designated transplant medical centers by highly trained transplant physicians. Favorable outcomes require careful screening for eligible recipients, as well as a well-calibrated live or deceased donor match.
Medical uses Liver transplantation is a potential treatment for acute or chronic conditions that cause irreversible and severe ("end-stage") liver dysfunction. Since the procedure carries relatively high risks, is resource-intensive, and requires major life modifications after surgery, it is reserved for dire circumstances. It has also emerged as an option for people whose colorectal cancer has metastasized to the liver. Judging the appropriateness or effectiveness of liver transplant on case-by-case basis is critically important (see Contraindications), as outcomes are highly variable.
Allocation Scoring systems are widely used to determine recipient benefit, and hence to allocate organs more fairly for transplantation.
MELD In the US, the Model for End Stage Liver Disease (MELD score) created by Dr. Patrick Kamath, for adults and the Pediatric End Stage Liver Disease (PELD score) for children younger than 12 years old are clinical scoring tools that consider various clinical criteria and are used to assess the need for a liver transplant. Higher scores for each clinical scoring tool indicate a higher severity of liver disease, and thus a greater need for a liver transplant. In those with chronic liver disease, a decompensating event such as hepatic encephalopathy, variceal bleeding, ascites, or spontaneous bacterial peritonitis may also signal a new need for a liver transplant.
Transplant Benefit Score The Transplant Benefit Score is an algorithmic medical scoring system used for making liver transplant waiting list decisions for the National Liver Offering Scheme in the United Kingdom. In 2023, an investigation by the Financial Times stated that the scoring system might result in younger patients not getting transplants under certain circumstances. A publication in The Lancet also showed that the TBS algorithm generated implausible results in some circumstances.
Contraindications Although liver transplantation is the most effective treatment for many forms of end-stage liver disease, the tremendous limitation in allograft (donor) availability and widely variable post-surgical outcomes make case selection critically important. Assessment of a person's transplant eligibility is made by a multi-disciplinary team that includes surgeons, medical doctors, psychologists, and other providers. The first step in evaluation is to determine whether the patient has irreversible liver-based disease, which can be cured by getting a new liver. Thus, those with diseases that are primarily based outside the liver or have spread beyond the liver are generally considered poor candidates. Some examples include:
someone with advanced liver cancer, with known/likely spread beyond the liver. Or those with cancer of any type, if the cancer cannot be treated successfully without rendering them unsuitable for transplant (other than skin cancers). active illicit substance use anatomic abnormalities that prevent liver transplantation severe heart/lung disease, whether it is primary heart/lung disease, or brought on by the liver disease (unless the team thinks they can still proceed) HIV/AIDS, especially if it is not well-managed (some persons with HIV/AIDS that have very low or undetectable viral loads could still be eligible) Importantly, many contraindications to liver transplantation are considered reversible; a person initially deemed "transplant-ineligible" may later become a favorable candidate if the circumstances change. Some examples include:
partial treatment of liver cancer, such that the risk of spread beyond the liver is decreased (for those with primary liver cancer or secondary spread to the liver, the medical team will likely rely heavily on the opinion of the patient's primary provider, the oncologist, and the radiologist) cessation of substance use (period of abstinence is variable) improvement in heart function, e.g. by percutaneous coronary intervention or bypass surgery treated HIV infection (see Special populations) Other conditions, including hemodynamic instability requiring vasopressor support, large liver cancers or those with invasion to blood vessels, intrahepatic cholangiocarcinoma, frailty, fulminant liver failure with suspected brain injury, alcohol use disorder with recent alcohol consumption, cigarette smoking, inadequate social support, and nonadherence to medical management may disqualify someone from liver transplantation, however these cases are usually evaluated by the multi-disciplinary transplant team on an individual basis.
Risks/complications
Graft rejection After a liver transplantation, immune-mediated rejection (also known as rejection) of the allograft may happen at any time. Rejection may present with lab findings: elevated AST, ALT, GGT; abnormal liver function values such as prothrombin time, ammonia level, bilirubin level, albumin concentration; and abnormal blood glucose. Physical findings may include encephalopathy, jaundice, bruising, and a bleeding tendency. Other nonspecific presentations may include malaise, anorexia, muscle aches, low fever, slight increase in white blood count, and graft-site tenderness. Three types of graft rejection may occur: hyperacute rejection, acute rejection, and chronic rejection.
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