Liver Transplant (LT) Workup
Lauren Sanchez
Transplant evaluation should not be started without first discussing with the transplant hepatology team.
- MELD-3.0 score: objective priority score for LT; adjusts for sex
- Uses: total bilirubin, creatinine, INR, albumin and Na.
- Exception points (HCC, HPS) can raise MELD into mid–high 20s even if native MELD is lower.
- Highest score is active for 7 days, then must be updated.
- Listing a pt for LT is determined by a multidisciplinary transplant committee
Indications | Contraindications* |
|---|---|
| Cirrhosis with MELD ≥ 15 or evidence of decompensation (ascites, variceal bleed, HE, HPS, portopulmonary hypertension) | Ongoing substance abuse (must have documented abstinence ≥ 3 mos) – refer to exception policy in Alcohol-associated Hepatitis section |
| Acute liver failure | Untreated or recurrent malignancy or metastatic disease |
| HCC that meets Milan criteria | Active infection, AIDS (CD4 <200) |
| Pts with early hilar cholangiocarcinoma (<3 cm in radial diameter) | Documented history of medical noncompliance |
| Other rare diseases (e.g., familial amyloid polyneuropathy or hyperoxaluria) | Lack of adequate social support |
| Anatomic contraindications: chronic cardiac/pulmonary conditions that significantly increase perioperative risk (e.g., severe pulm hypertension, heart failure) | |
| Fulminant hepatic failure with sustained ICP >50mmHg or CPP <40mmHg | |
| * Advanced age (>70) and BMI >40 or <18.5 are no longer contraindications for liver transplantation on their own/td> | |
Evaluation
- Imaging: Abdominal CT (triple phase) or MRI (multiphase with contrast) to evaluate for hepatic malignancy and vascular anatomy
- Infectious workup: TB testing, HIV, RPR, VZV, CMV, EBV, and Hepatitis A, B, and C
- PFT’s, carotid US
- Cardiac evaluation: 1) TTE for structure/function and RVSP --> if RVSP > 40mmHg on TTE, then R Heart Catheterization is indicated and 2) Coronary calcium score vs. Coronary CT Angiogram depending on patient risk factors
- Malignancy screening: CXR in all patients, CT Chest in prior/current smokers, colonoscopy, pap smear, mammogram, and PSA if applicable
- Panorex to identify dental disease; consult OMFS pending results
- DEXA scan (osteoporosis in up to 55% of individuals with cirrhosis)
- Psychosocial/ Substance use
- Certification of completion of intensive outpatient program (IOP) for substance abuse
- Psychosocial evaluation (consult Psychiatry, social work)
When to think about simultaneous liver kidney transplant (SLKT)?
- CKD <30mL/min after > 90 days of eGFR<60 or
- AKI dependent on dialysis >8 weeks or
- Extensive glomerulosclerosis present
- *Current VUMC policy: pts should be abstinent from alcohol for no less than 3-6 months, although exceptions may be made for early liver transplant based on a very strict protocol. Discuss exception criteria with attending if suspect patient unlikely to survive hospitalization without transplant
- *Deceased donor transplants are offered at VUMC. At time of this document, living liver donation is not an option currently at VUMC.