Transplantation for End-Stage Liver Disease
Liver transplantation is often the only reasonable option for the treatment of end-stage liver disease (ESLD). Although chronic liver disease from hepatitis C is the most common cause, a wide variety of other liver conditions can result in ESLD.
ESLD is defined as acute or chronic liver failure that will be fatal without liver replacement. The United Network for Organ Sharing (UNOS) has adopted the Model for End-Stage Liver Disease (MELD), a severity-of-illness scoring system for ranking patients on the waiting list and allocating organs. MELD scores are closely correlated with short-term survival in patients with liver failure.
Transplantation offers a survival benefit for patients with a MELD score of 15 or higher. Most of these patients will exhibit some or all the stigmata of decompensated liver disease, including ascites, encephalopathy, jaundice and muscle wasting. For liver transplant candidates, the higher the MELD score, the higher the ranking on the waiting list.
Some patients may have greater functional disability than others. However, refractory ascites, for example, may be associated with significant morbidity and may not correlate with the MELD score. In patients who are underserved by MELD, access to organs may prove difficult, and an alternative, such as living donation, may be required.
The timing of transplantation in patients with liver cancer is complex and driven by many factors, including the risk of cancer progression and the severity of underlying liver disease. Complications of liver disease from cancer are not reflected in MELD scores. However, UNOS does permit MELD exceptions, which can shorten the waiting time for transplant candidates with liver cancer.
Reducing the Wait for a Donor Liver
The waiting time for a donor liver is based on severity of illness and blood type. Patients may be waitlisted in multiple centers in different regions to improve their chances of receiving a donor liver that is the best match.
Possible alternatives to transplantation are discussed with each patient during transplant education. One option is the identification of a healthy donor to provide a portion of his or her liver. Another option is to receive a deceased donor liver that may be at increased risk of poor graft function or disease transmission. In some cases, this type of "expanded criteria" organ may be acceptable and potentially preferable to long wait times.
A Comprehensive Transplantation Evaluation Process
The Liver Center will evaluate any patient referred for an opinion regarding liver transplant candidacy. Not every patient requires a full evaluation; patients who may be too well for transplantation may continue to be followed by their primary doctors, with a full evaluation initiated only when appropriate.
A full transplant evaluation is a comprehensive process that includes extensive patient and family education, multiple physician assessments by our multidisciplinary team and aggressive medical and psychosocial intervention to prepare the patient for liver transplantation. Once a patient is listed for transplantation, our team becomes intimately and directly involved in all aspects of the patient's care in order to prevent complications that could interfere with his or her active status on the waiting list.
Optimal Graft Selection Helps Ensure Success
To optimize post-transplant outcomes, attending transplant surgeons directly assess and procure most donor organs used for transplantation at Montefiore rather than relying on evaluations by trainees or outside medical personnel. All liver implantations are performed by two attending liver transplant surgeons to minimize the risk of complications, shorten operative time and reduce blood product utilization.
The liver anesthesia team utilizes advanced techniques such as blood recycling during transplantation to minimize use of blood products. This enables some liver transplants to be performed without a blood transfusion.
Better Immunosuppression Options
Post-transplant immunosuppression regimens are individualized, with an overall goal of minimizing immunosuppression whenever possible. The aim is to discontinue steroids within the first week, rather than the first year, as is common in most programs. This protocol is based on recent findings suggesting that less immunosuppression may reduce recurrent disease related to HCV.
By the end of their first post-transplant year, virtually all patients are maintained on only one immunosuppressive agent.
Coordinated Follow-Up Care for Life
After transplantation, a full multidisciplinary team of medical and surgical specialists, nurse coordinators, nutritionists and psychosocial professionals will continue to provide care for life. In many cases, however, patients are able to return to their community physicians for routine care within a few months following successful transplantation.