Indications and Contraindications for Liver Transplantation
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