Referral Process

Referral Checklist

Referral Form

Considerations When Referring for Liver Transplant

Pre-Liver Transplant Evaluation Protocol

All patients referred for Liver Transplant Evaluation will be reviewed by the nurse coordinator.

If any of the following exist, the patient will be scheduled for a Hepatology consult and Liver Transplant Surgery consult only:

• Use of alcohol or drugs in the last 6 months
• Significant comorbid medical history
• History of cancer in the previous two years
• MELD score below 7
• Ideal Body Weight greater than 150%
• Age of patient greater than 75 years old

Coordinators may discuss any case with Hepatologist or Liver Transplant Surgeon prior to scheduling to determine appropriate tests.

Transplant Eligibility Criteria

• End-stage liver disease
• Absence of serious systemic illness or other medical conditions that may affect immediate or long-term survival.
• Full understanding of transplant procedure, its limitations and long-term compliance to follow-up requirements.
• Strong social support network.
• Free from active drug, nicotine or alcohol abuse.
• Weight less than 150% of IBW.

Patients who do not meet the above criteria at the time of referral will be given the opportunity to fulfill these criteria and undergo re-evaluation. Formal input from the psychiatry staff is required to assess the risk of return to alcohol use following liver transplantation.

Indications for Liver Transplant

• Presence of irreversible liver disease and a life expectancy of less than 12 months with no effective medical or surgical alternatives to transplantation
• Chronic liver disease that has progressed to the point of significant interference with the patient's ability to work or with his/her quality of life
• Progression of liver disease that will predictably result in mortality exceeding that of transplantation (85% one-year patient survival and 70% five-year survival)
• Cholestatic Diseases: primary biliary cirrhosis, sclerosing cholangitis, secondary biliary cirrhosis, biliary atresia, cystic fibrosis
• Chronic Hepatitis: hepatitis B, hepatitis C, hepatitis D, autoimmune chronic active hepatitis, cryptogenic cirrhosis, chronic drug toxicity or toxin exposure
• Alcoholic Cirrhosis: Patients with alcoholic cirrhosis are considered for transplant if they meet current criteria for abstinence and rehabilitation.
• Metabolic Diseases: hemochromatosis, Wilson's disease, Alpha-1-antitrypsin deficiency, glycogen storage disease, tyrosinemia, familial amyloidotic polyneuropathy, other metabolic disorders treatable by liver replacement.
• Fulminant Acute Hepatic Necrosis: viral hepatitis, drug toxicity, toxin, Wilson's disease.
• Primary Hepatic Tumors: selected patients with hepatocellular carcinoma

Manifestations of End-Stage Liver Disease

• Progressive jaundice
• Intractable ascites
• Spontaneous bacterial peritonitis
• Hepatorenal Syndrome
• Encephalopathy
• Variceal bleeding
• Intractable pruritus
• Chronic fatigue (such as resulting in loss of gainful employment)
• Bleeding diathesis or coagulopathy

Specific Biochemical and Clinical Indications for Liver Transplantation

Cholestatic liver disease

• Serum albumin < 3.0 g/dL
• Intractable pruritus
• Progressive bone disease
• Recurrent bacterial cholangitis

Hepatocellular liver disease

• Serum albumin in < 3.0 g/d L
• Prothrombin time >3 seconds above control

Both cholestatic and hepatocellular liver disease

• Recurrent or severe hepatic encephalopathy
• Refractory ascites
• Spontaneous bacterial peritonitis
• Recurrent portal hypertensive bleeding
• Severe chronic fatigue and weakness
• Progressive malnutrition
• Development of hepatorenal syndrome
• Detection of small, coincidental hepatocellular carcinoma

Absolute Contraindications for Liver Transplant

Factors which place individual at highest risk for poor outcome,
poor quality of life or increased mortality

If your doctor thinks you might need a liver transplant, then you should do everything you can to keep healthy and strong. Some of the things that might prevent you from getting a liver transplant include:

• Continuing to use alcohol or illegal drugs
• Being at high risk of using drugs or alcohol again after the surgery
• Being unable to follow your doctor's instructions, like taking your medicine when you are supposed to
• Having too little support from people at home to care for you after the operation
• Having advanced cancer of the liver
• Having another kind of cancer in the past 3 to 5 years
• Having severe heart, lung or kidney disease
• Having advanced HIV disease (AIDS)
• Severe hardening of the arteries
• Systemic infections

Relative Contraindications for Liver Transplant

Factors which place individual at higher risk for poor outcome,
poor quality of life or increased mortality

• Obesity (>150% of IBW).
• Active systemic illness that would limit long-term survival.
• Previous extra hepatic malignancies
• Prior portosystemic shunts
• Malnutrition

Transplant Center