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Sunday, January 27, 2008

Who Qualifies?

Alcoholic liver disease accounts for about 20% of all liver transplants. Although patients with liver failure due to liver disease of any etiology are candidates, patients with active alcoholism and substance abuse should not be considered because recidivism rates are high in this group. On the other hand, a remote history does not preclude consideration. Current recommendations are: abstinence for longer than 6 months, successful completion of a formally approved program for rehabilitation from substance abuse, and the existence of a favorable living environment after subjective evaluation by a psychiatric social worker.

Cirrhosis due to autoimmune, cryptogenic, cholestatic (biliary cirrhosis, primary sclerosing cholangitis, biliary atresia), metabolic, and genetic diseases comprise the remaining indications for liver transplantation.

For acute liver failure, regardless of etiology, liver transplantation is the treatment of choice, provided this can be achieved before the patient develops deep encephalopathy, irreversible brain edema, and herniation. Patients with early stage hepatocellular carcinoma can be successfully transplanted while those with more advanced disease are not usually considered candidates for liver transplantation unless they are first treated successfully under specific chemotherapy protocols
Selecting Candidates for Liver Transplantation
Liver transplantation has emerged from its status as an experimental procedure in 1960s to its current position as the preferred treatment and only cure for end-stage liver disease. Increasing numbers of patients on the waiting list and the traditionally small pool of donor organs have prompted the establishment of formal listing criteria to optimize organ utilization.

There are no age limits when considering patients for liver transplantation. The absence of significant disease in the heart, brain, lungs, and kidney would favor consideration for transplantation regardless of age. A patent portal or superior mesenteric vein is necessary for successful engraftment. If evidence of partial or complete thrombosis is apparent on initial imaging studies, then angiographic confirmation is recommended. Hepatopulmonary syndrome (hypoxemia related to cirrhosis) occurs occasionally and usually subsides following transplantation. Significant pulmonary hypertension, on the other hand, precludes transplantation since cardiac deterioration following engraftment inevitably occurs and is usually fatal. Patients who are HIV positive or who have psychiatric diseases such as depression and psychosis are not suitable candidates. Patients with a remote (greater than 5 years) history of malignancy in a nonhepatic site may be considered for liver transplantation. Patients with advanced primary liver cancer and secondary cancer deposits in liver from primary outside are not suitable for liver transplantation.
The timing of liver transplantation in end-stage liver disease is not clearly established. Advanced cirrhosis is complicated by variceal hemorrhage, ascites, encephalopathy, hepatorenal syndrome, and hepatocellular carcinoma. A number of treatment options are available for the therapy of these complications. However, the referral of patients for transplantation after severe decompensation, i.e., in the face of severe malnutrition, aspiration pneumonia, ARDS, persistent gastrointestinal hemorrhage or renal failure, bodes a poor outcome. Hence all patients with severe acute liver failure and patients with cirrhosis who have developed only sign of liver failure (Ref --) should consult a transplant center.

In the United States, the most common indication (20-30%) for liver transplantation is cirrhosis due to chronic viral hepatitis. Although viral hepatitis B and hepatitis C recur frequently in the transplanted liver, the administration of high doses of hepatitis B immune globulin at frequent established intervals following transplant has reduced the recurrence rates of hepatitis B significantly, improving both graft and patient survival. The administration of the nucleoside analogue, lamivudine, to patients prior to transplant is expected to reduce viral replication and promises to enhance this benefit. The progression to cirrhosis in about 10-20% of patients with hepatitis C permits consideration for transplantation in these patients. However, there are no strategies to prevent the recurrence of hepatitis C in the post-transplant period as exist for hepatitis B, and the majority of patients develop recurrent hepatitis C soon after transplantation. However, long-term survival is the rule in these patients although there may be a slow progression to cirrhosis

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