Liver transplantation in adults: Patient selection and pretransplantation evaluation
- Lorna M Dove, MD, MPH
Lorna M Dove, MD, MPH
- Assistant Professor, Department of Medicine
- Columbia University
- Robert S Brown, Jr, MD, MPH
Robert S Brown, Jr, MD, MPH
- Section Editor — Liver Transplantation
- Vice Chair, Transitions of Care, Department of Medicine
- Interim Chief, Division of Gastroenterology and Hepatology
- Weill Cornell Medical College
- Professor of Clinical Medicine, Columbia University College of Physicians & Surgeons
Liver transplantation is an important treatment option for patients with acute liver failure, end-stage liver disease, and primary hepatic malignancy, though it is not the initial or primary treatment modality for most liver diseases.
Transplantation infrequently cures the underlying disease; recurrent liver disease after transplantation occurs in 0 to 100 percent of patients, depending on the disease for which transplantation was performed. Thus, the decision to list a patient for transplantation is a risk-benefit analysis in which the inherent risks of surgery, recurrent disease, and long-term immunosuppression must be weighed against the potential benefits of transplantation. These benefits differ for each patient but include improvements in survival, prevention of long-term complications, and better health-related quality of life. In most cases, the risks associated with recurrent disease do not outweigh the benefits of liver transplantation.
This topic will review the selection of patients for liver transplantation and the pretransplantation evaluation. Other issues related to liver transplantation including donor selection, living donor liver transplantation, ethical issues in liver transplantation, immunosuppression following liver transplantation, and the medical management of patients who have undergone liver transplantation are discussed elsewhere. (See "Liver transplantation: Donor selection" and "Living donor liver transplantation" and "Ethical issues in liver transplantation" and "Liver transplantation in adults: Overview of immunosuppression" and "Liver transplantation in adults: Long-term management of transplant recipients".)
In 2013, the American Association for the Study of Liver Diseases and the American Society of Transplantation developed guidelines regarding the indications for liver transplantation and the evaluation of patients being considered for liver transplantation . The discussion that follows is generally consistent with those guidelines.
FREQUENCY OF LIVER TRANSPLANTATION BY UNDERLYING LIVER DISEASE
According to the United Network for Organ Sharing/Organ Procurement and Transplantation Network registry, hepatocellular carcinoma and hepatitis C virus cirrhosis are the most common diseases leading to liver transplantation, although increasing numbers of patients with alcoholic cirrhosis and nonalcoholic steatohepatitis are receiving transplants . For additional information, see optn.transplant.hrsa.gov/data/view-data-reports.To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:
- Martin P, DiMartini A, Feng S, et al. Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. Hepatology 2014; 59:1144.
- Yang JD, Larson JJ, Watt KD, et al. Hepatocellular Carcinoma Is the Most Common Indication for Liver Transplantation and Placement on the Waitlist in the United States. Clin Gastroenterol Hepatol 2017; 15:767.
- Ostapowicz G, Fontana RJ, Schiødt FV, et al. Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. Ann Intern Med 2002; 137:947.
- Eghtesad B, Aucejo F. Liver transplantation for malignancies. J Gastrointest Cancer 2014; 45:353.
- Longeville JH, de la Hall P, Dolan P, et al. Treatment of a giant haemangioma of the liver with Kasabach-Merritt syndrome by orthotopic liver transplant a case report. HPB Surg 1997; 10:159.
- Tepetes K, Selby R, Webb M, et al. Orthotopic liver transplantation for benign hepatic neoplasms. Arch Surg 1995; 130:153.
- Russo MW, Johnson MW, Fair JH, Brown RS Jr. Orthotopic liver transplantation for giant hepatic hemangioma. Am J Gastroenterol 1997; 92:1940.
- Herlenius G, Wilczek HE, Larsson M, et al. Ten years of international experience with liver transplantation for familial amyloidotic polyneuropathy: results from the Familial Amyloidotic Polyneuropathy World Transplant Registry. Transplantation 2004; 77:64.
- Tsuchiya A, Yazaki M, Kametani F, et al. Marked regression of abdominal fat amyloid in patients with familial amyloid polyneuropathy during long-term follow-up after liver transplantation. Liver Transpl 2008; 14:563.
- Benson MD. Liver transplantation and transthyretin amyloidosis. Muscle Nerve 2013; 47:157.
- Kemmer N, Kaiser T, Zacharias V, Neff GW. Alpha-1-antitrypsin deficiency: outcomes after liver transplantation. Transplant Proc 2008; 40:1492.
- Carey EJ, Iyer VN, Nelson DR, et al. Outcomes for recipients of liver transplantation for alpha-1-antitrypsin deficiency–related cirrhosis. Liver Transpl 2013; 19:1370.
- Brandhagen DJ, Alvarez W, Therneau TM, et al. Iron overload in cirrhosis-HFE genotypes and outcome after liver transplantation. Hepatology 2000; 31:456.
- Kowdley KV, Brandhagen DJ, Gish RG, et al. Survival after liver transplantation in patients with hepatic iron overload: the national hemochromatosis transplant registry. Gastroenterology 2005; 129:494.
- Mathurin P, Moreno C, Samuel D, et al. Early liver transplantation for severe alcoholic hepatitis. N Engl J Med 2011; 365:1790.
- Cross TJ, Antoniades CG, Muiesan P, et al. Liver transplantation in patients over 60 and 65 years: an evaluation of long-term outcomes and survival. Liver Transpl 2007; 13:1382.
- Roland MS, Carlson L. Liver and kidney transplantation in HIV-infected patients: A preliminary multi-site experience. 9th Conference on Retroviruses and Opportunistic Infections; February 24-28, 2002; Seattle, Washington. Abstract 655.
- Ragni M NG, Heaton N. Antiretroviral therapy and mortality among HIV-positive liver transplant recipients. 9th Conference on Retroviruses and Opportunistic Infections; February 24-28 2002; Seattle, Washington. Abstract 125.
- Prachalias AA, Pozniak A, Taylor C, et al. Liver transplantation in adults coinfected with HIV. Transplantation 2001; 72:1684.
- Fung J. Clinical experiences with HIV and transplantation. Oral Presentation. American Society of Transplantation (AST) Winter Symposium; January 19, 2002; Olympic Valley, California.
- Wreghitt T. Liver Transplantation in Adults Coinfected With HIV. Transplantation 2001; 72: 1684. Transplantation 2001; 72:1594.
- Stock P, Roland M, Carlson L, et al. Solid organ transplantation in HIV-positive patients. Transplant Proc 2001; 33:3646.
- Stock PG, Roland ME, Carlson L, et al. Kidney and liver transplantation in human immunodeficiency virus-infected patients: a pilot safety and efficacy study. Transplantation 2003; 76:370.
- Neff GW, Bonham A, Tzakis AG, et al. Orthotopic liver transplantation in patients with human immunodeficiency virus and end-stage liver disease. Liver Transpl 2003; 9:239.
- Cooper C, Kanters S, Klein M, et al. Liver transplant outcomes in HIV-infected patients: a systematic review and meta-analysis with synthetic cohort. AIDS 2011; 25:777.
- Mindikoglu AL, Regev A, Magder LS. Impact of human immunodeficiency virus on survival after liver transplantation: analysis of United Network for Organ Sharing database. Transplantation 2008; 85:359.
- Terrault NA, Roland ME, Schiano T, et al. Outcomes of liver transplant recipients with hepatitis C and human immunodeficiency virus coinfection. Liver Transpl 2012; 18:716.
- Zoghbi GJ, Patel AD, Ershadi RE, et al. Usefulness of preoperative stress perfusion imaging in predicting prognosis after liver transplantation. Am J Cardiol 2003; 92:1066.
- Colle IO, Moreau R, Godinho E, et al. Diagnosis of portopulmonary hypertension in candidates for liver transplantation: a prospective study. Hepatology 2003; 37:401.
- Guckelberger O, Mutzke F, Glanemann M, et al. Validation of cardiovascular risk scores in a liver transplant population. Liver Transpl 2006; 12:394.
- Plotkin JS, Scott VL, Pinna A, et al. Morbidity and mortality in patients with coronary artery disease undergoing orthotopic liver transplantation. Liver Transpl Surg 1996; 2:426.
- Krowka MJ, Mandell MS, Ramsay MA, et al. Hepatopulmonary syndrome and portopulmonary hypertension: a report of the multicenter liver transplant database. Liver Transpl 2004; 10:174.
- Starkel P, Vera A, Gunson B, Mutimer D. Outcome of liver transplantation for patients with pulmonary hypertension. Liver Transpl 2002; 8:382.
- Harinstein ME, Iyer S, Mathier MA, et al. Role of baseline echocardiography in the preoperative management of liver transplant candidates. Am J Cardiol 2012; 110:1852.
- Lentine KL, Costa SP, Weir MR, et al. Cardiac disease evaluation and management among kidney and liver transplantation candidates: a scientific statement from the American Heart Association and the American College of Cardiology Foundation. J Am Coll Cardiol 2012; 60:434.
- Raval Z, Harinstein ME, Skaro AI, et al. Cardiovascular risk assessment of the liver transplant candidate. J Am Coll Cardiol 2011; 58:223.
- Prentis JM, Manas DM, Trenell MI, et al. Submaximal cardiopulmonary exercise testing predicts 90-day survival after liver transplantation. Liver Transpl 2012; 18:152.
- Arguedas MR, Singh H, Faulk DK, Fallon MB. Utility of pulse oximetry screening for hepatopulmonary syndrome. Clin Gastroenterol Hepatol 2007; 5:749.
- Brown RS Jr, Russo MW, Lai M, et al. A survey of liver transplantation from living adult donors in the United States. N Engl J Med 2003; 348:818.
- FREQUENCY OF LIVER TRANSPLANTATION BY UNDERLYING LIVER DISEASE
- Acute liver failure
- Liver neoplasms
- Metabolic disorders
- PRETRANSPLANTATION EVALUATION
- Laboratory testing
- Cardiopulmonary evaluation
- - Electrocardiogram
- - Cardiac stress testing
- - Echocardiography
- - Pulse oximetry
- - Additional testing for pulmonary disease
- Cancer screening
- Infectious disease evaluation and vaccinations
- Hepatic imaging and HCC staging
- Upper endoscopy
- Bone density testing
- Psychosocial evaluation and education
- ADULT LIVING DONOR LIVER TRANSPLANTATION
- INFORMATION FOR PATIENTS
- SUMMARY AND RECOMMENDATIONS