Liver transplantation indications: Difference between revisions

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__NOTOC__
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{{CMG}}; {{AE}} {{MAD}}
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{{liver transplantation}}
{{liver transplantation}}


--Overview--
== Overview ==
 
Indications for liver transplantation include [[acute liver failure]], [[Cirrhosis|cirrhosis,]] [[Liver neoplasms]], and metabolic disorders such as [[Familial amyloid polyneuropathy]], [[Primary hyperoxaluria]], [[Cystic fibrosis]], [[Alpha 1-antitrypsin deficiency|alpha-1 antitrypsin deficiency]], [[glycogen storage disease]], t[[Tyrosinemia|yrosinemia]], h[[Hemochromatosis|emochromatosis]], [[Wilson's disease|Wilson disease]], and [[Acute intermittent porphyria]].
Indications
Acute liver failure
Acute liver failure is defined by the development of severe acute liver injury with encephalopathy and impaired synthetic function (international normalized ratio [INR] of ≥1.5) in a patient without cirrhosis or preexisting liver disease.
viral and drug-induced hepatitis are the most common causes of acute liver failure in adults. [3]  
 
Cirrhosis
manifestation of compromised hepatic function [1].
Variceal hemorrhage, ascites, and encephalopathy are the primary manifestations of end-stage liver disease and are designated as markers of decompensation. development of hepatorenal syndrome,
Patients with cirrhosis are typically candidates for liver transplantation once their biologic Model for End-stage Liver Disease (MELD) score is ≥15 (calculator 1 and calculator 2). However, some patients with Child B cirrhosis (table 2) with portal hypertension but a low MELD score may be candidates for liver transplantation.
The transplantation evaluation is typically started once a patient has a MELD score >10.
This permits the patient to meet the transplantation team prior to the development of end-stage liver disease and ensures adequate time for the patient to complete the pretransplantation evaluation.
 
Patients may also qualify for liver transplantation if they have a complication or condition that qualifies for standard MELD exception points.
Conditions include
●Hepatocellular carcinoma.
●Hepatopulmonary syndrome.
●Portopulmonary hypertension (provided the mean arterial pressure can be maintained at <35 mmHg with treatment).
●Familial amyloid polyneuropathy.
●Primary hyperoxaluria.
●Cystic fibrosis.
●Hilar cholangiocarcinoma (provided the liver transplantation center has a UNOS-approved protocol detailing the work-up and management of patients with cholangiocarcinoma undergoing transplantation).
●Hepatic artery thrombosis (occurring within 14 days of liver transplantation but not meeting criteria for status 1A).
 
Liver neoplasms
 
Patients with some primary liver neoplasms may be candidates for liver transplantation, provided the neoplasms meet specific criteria (eg, for patients with hepatocellular carcinoma [HCC], a single lesion ≤5 cm or up to three separate lesions all <3 cm, no evidence of gross vascular invasion, and no regional nodal or distant metastases). In addition, there may be a role for liver transplantation in patients with neuroendocrine tumors that have metastasized to the liver, but experience in this setting is limited [4].
 
Some of the liver neoplasms that have been treated with liver transplantation include [4]:
●HCC
 
For patients with localized HCC who are candidates for surgical resection, we recommend resection rather than transplantation
 
●For patients who are not candidates for resection and who have a single lesion ≤5 cm, no more than three separate lesions, none larger than 3 cm, no evidence of gross vascular invasion, and no regional nodal or distant metastases, we recommend liver transplantation (Grade 1B). When these criteria are strictly applied, five-year survival rates of 75 percent or higher can be achieved. INDICATIONS FOR TRANSPLANTATION
 
For patients with localized HCC who are not candidates for resection, orthotopic liver transplantation is an appropriate strategy for patients with a single lesion ≤5 cm, up to three separate lesions, none larger than 3 cm, no evidence of gross vascular invasion, and no regional nodal or extrahepatic distant metastases. When these criteria are strictly applied, five-year survival rates 75 percent or higher can be achieved. Overall survival in carefully selected patients undergoing orthotopic liver transplantation (OLT) for HCC is similar to or only slightly worse than the survival of patients undergoing OLT for nonmalignant causes. Although randomized trials have not been carried out, uncontrolled series suggest that survival following OLT is as good or better than it is after alternative treatments for HCC in carefully selected patients.
The landmark study of Mazzaferro in 1996 established deceased-donor liver transplantation (OLT) as a viable option for the treatment of hepatocellular carcinoma (HCC) [5]. They showed that when transplantation was restricted to patients with early HCC (defined as single lesion ≤5 cm, up to three separate lesions, none larger than 3 cm, no evidence of gross vascular invasion, and no regional nodal or distant metastases), a four-year survival rate of 75 percent could be achieved. These outcomes are similar to expected survival rates for patients undergoing transplantation for cirrhosis without HCC. These criteria have become known as the Milan criteria and have been widely applied around the world in the selection of patients with HCC for liver transplantation [5].
Considerable interest has arisen in expansion of these transplant criteria in highly specialized centers, although such expanded criteria remain purely investigational at present. This subject is discussed in detail below. (See 'Expanded transplant criteria' below.)
Extrahepatic staging in patients being considered for transplantation should include computed tomography (CT) of the chest and CT or magnetic resonance imaging (MRI) of the abdomen and pelvis [6]. Bone scan was previously required, but this was changed in December 2012. (See 'Requirements for listing and management while on the wait list' below.)
 
●Prelisting biopsy is not mandatory. However, in the United States, requirements for listing for liver transplantation from the United Network for Organ Sharing (UNOS) require that patients have imaging findings that are consistent with HCC; only class 5 nodules meet imaging criteria for listing for transplantation (table 4).
 
 
 
●Epithelioid hemangioendothelioma [5-7]
 
●Large hepatic adenomas
 
Metabolic disorders
Liver-based metabolic conditions that have been treated with liver transplantation include:
●Familial amyloid polyneuropathy (qualifies for standard MELD exception points) [8-10].
 
●Primary hyperoxaluria (qualifies for standard MELD exception points)
 
●Cystic fibrosis (qualifies for standard MELD exception points)
 
●Alpha-1 antitrypsin deficiency [11,12].
 
 
●Some forms of glycogen storage disease (type I and type IV)
The optimal transplantation strategy for patients with PH type 1 remains uncertain [81]. Three different transplant options are available.
●Combined liver and kidney transplantation
●Isolated liver transplantation
●Isolated renal transplantation
 


●Tyrosinemia
== Indications ==
OLT is performed in patients with persistent liver failure who do not respond to nitisinone therapy or have hepatic malignancy [39-41].


●Hemochromatosis [13,14]
=== Acute liver failure ===
* Acute liver failure is defined by the development of severe acute liver injury with encephalopathy and impaired synthetic function.<ref name="pmid12484709">{{cite journal| author=Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH et al.| title=Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States. | journal=Ann Intern Med | year= 2002 | volume= 137 | issue= 12 | pages= 947-54 | pmid=12484709 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=12484709  }}</ref>


=== Cirrhosis ===
* Patients with cirrhosis are typically candidates for liver transplantation once their biologic [[Model for End-Stage Liver Disease|Model for End-stage Liver Disease]] ([[MELD Score|MELD]]) score is ≥15.<ref name="pmid24716201">{{cite journal| author=Martin P, DiMartini A, Feng S, Brown R, Fallon M| title=Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation. | journal=Hepatology | year= 2014 | volume= 59 | issue= 3 | pages= 1144-65 | pmid=24716201 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24716201  }}</ref>
* Variceal [[hemorrhage]], [[ascites]], and [[encephalopathy]] are the markers of [[decompensation]]. 
* Some patients with [[Child-Pugh B|Child B cirrhosis]] with [[portal hypertension]] but a low [[MELD Score|MELD score]] may be candidates for liver transplantation. 
* The transplantation evaluation is started once a patient has a MELD score >10. 
* Patients may also qualify for liver transplantation if they have a complication or condition that qualifies for standard MELD exception points:
* [[Hepatocellular carcinoma]]
* [[Hepatopulmonary syndrome]]
* [[Portopulmonary hypertension]] (<35 mmHg )
* [[Familial amyloid polyneuropathy]]
* [[Primary hyperoxaluria]]
* [[Cystic fibrosis]]
=== Liver neoplasms ===
* [[Hepatocellular carcinoma]]


●Wilson disease
* Patients with some primary [[liver neoplasms]] may be candidates for liver transplantation, provided the neoplasms meet specific criteria:<ref name="pmid24604263">{{cite journal| author=Eghtesad B, Aucejo F| title=Liver transplantation for malignancies. | journal=J Gastrointest Cancer | year= 2014 | volume= 45 | issue= 3 | pages= 353-62 | pmid=24604263 | doi=10.1007/s12029-014-9590-2 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24604263  }}</ref>
Liver transplantation may be the only option for patients who present with acute liver failure and in those with decompensated liver disease who are unresponsive to drug therapy [82-86]. For those with advanced liver disease, a prognostic scoring system for children with Wilson disease presenting with failure was proposed by a group at Kings College and then later revised [87,88]. The revised system (based upon an index of serum bilirubin, the prothrombin time international normalized ratio [INR], aspartate aminotransferase level, and white blood cell count) had a sensitivity, specificity, and positive predictive value for determining the need for liver transplantation of 93, 98, and 88 percent, respectively [88]. This scoring system has been validated in pediatric and adult patients.
* A single lesion ≤5 cm
* Up to three separate lesions all <3 cm, no evidence of gross vascular invasion, and no regional nodal or distant [[Metastasis|metastases]]
* Expansion criteria known as the Milan criteria for liver transplantation are for patients who are not candidates for resection and who have a single lesion ≤5 cm, no more than three separate lesions, none larger than 3 cm, no evidence of gross vascular invasion, and no regional nodal or distant [[Metastasis|metastases]].<ref name="pmid9174860">{{cite journal| author=Longeville JH, de la Hall P, Dolan P, Holt AW, Lillie PE, Williams JA et al.| title=Treatment of a giant haemangioma of the liver with Kasabach-Merritt syndrome by orthotopic liver transplant a case report. | journal=HPB Surg | year= 1997 | volume= 10 | issue= 3 | pages= 159-62 | pmid=9174860 | doi= | pmc=2423854 | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=9174860  }}</ref>
* [[Hemangioendothelioma|Epithelioid hemangioendothelioma]]<ref name="pmid7848084">{{cite journal| author=Tepetes K, Selby R, Webb M, Madariaga JR, Iwatsuki S, Starzl TE| title=Orthotopic liver transplantation for benign hepatic neoplasms. | journal=Arch Surg | year= 1995 | volume= 130 | issue= 2 | pages= 153-6 | pmid=7848084 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7848084  }}</ref>
* Large [[Hepatocellular adenoma|hepatic adenomas]]


●Acute intermittent porphyria
=== Metabolic disorders ===
Reasonable indications for liver transplantation include frequent hospitalizations, unresponsiveness to hemin, and poor quality of life. However, it is often difficult to weigh the risks and benefits of liver transplantation because of the unpredictable natural course of the disease, which may progress or improve.  
Liver-based metabolic conditions that have been treated with liver transplantation include:<ref name="pmid24019185">{{cite journal| author=Carey EJ, Iyer VN, Nelson DR, Nguyen JH, Krowka MJ| title=Outcomes for recipients of liver transplantation for alpha-1-antitrypsin deficiency–related cirrhosis. | journal=Liver Transpl | year= 2013 | volume= 19 | issue= 12 | pages= 1370-6 | pmid=24019185 | doi=10.1002/lt.23744 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=24019185  }}</ref><ref name="pmid16083706">{{cite journal| author=Kowdley KV, Brandhagen DJ, Gish RG, Bass NM, Weinstein J, Schilsky ML et al.| title=Survival after liver transplantation in patients with hepatic iron overload: the national hemochromatosis transplant registry. | journal=Gastroenterology | year= 2005 | volume= 129 | issue= 2 | pages= 494-503 | pmid=16083706 | doi=10.1016/j.gastro.2005.05.004 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=16083706  }}</ref><ref name="pmid18383093">{{cite journal| author=Tsuchiya A, Yazaki M, Kametani F, Takei Y, Ikeda S| title=Marked regression of abdominal fat amyloid in patients with familial amyloid polyneuropathy during long-term follow-up after liver transplantation. | journal=Liver Transpl | year= 2008 | volume= 14 | issue= 4 | pages= 563-70 | pmid=18383093 | doi=10.1002/lt.21395 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=18383093  }}</ref>
* [[Familial amyloid polyneuropathy]]
* [[Primary hyperoxaluria]]
* [[Cystic fibrosis]]
* [[Alpha 1-antitrypsin deficiency|Alpha-1 antitrypsin deficiency]]
* Some forms of [[glycogen storage disease]]
* [[Tyrosinemia]]: LT is performed in patients with persistent liver failure who do not respond to nitisinone therapy or have hepatic malignancy
* [[Hemochromatosis]]
* [[Wilson's disease|Wilson disease]]: For those with advanced liver disease, a prognostic scoring system for children with Wilson disease presenting with failure was proposed by a group at Kings College and then later revised.  
* [[Acute intermittent porphyria]]


liver transplantation is usually reserved for patients who have developed end-stage liver disease or HCC.
==References==
{{Reflist|2}}

Latest revision as of 21:01, 18 December 2017


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Mohammed Abdelwahed M.D[2]

Liver trasnsplantation Microchapters

Home

Patient Information

Overview

Historical Perspective

Indications

Pre-surgical management

Choice of donor

Epidemiology and Demographics

Techniques

Complications

Acute rejection

Immune therapy

Post-surgical infection

Prognosis

Overview

Indications for liver transplantation include acute liver failure, cirrhosis, Liver neoplasms, and metabolic disorders such as Familial amyloid polyneuropathy, Primary hyperoxaluria, Cystic fibrosis, alpha-1 antitrypsin deficiency, glycogen storage disease, tyrosinemia, hemochromatosis, Wilson disease, and Acute intermittent porphyria.

Indications

Acute liver failure

  • Acute liver failure is defined by the development of severe acute liver injury with encephalopathy and impaired synthetic function.[1]

Cirrhosis

Liver neoplasms

  • Patients with some primary liver neoplasms may be candidates for liver transplantation, provided the neoplasms meet specific criteria:[3]
  • A single lesion ≤5 cm
  • Up to three separate lesions all <3 cm, no evidence of gross vascular invasion, and no regional nodal or distant metastases
  • Expansion criteria known as the Milan criteria for liver transplantation are for patients who are not candidates for resection and who have a single lesion ≤5 cm, no more than three separate lesions, none larger than 3 cm, no evidence of gross vascular invasion, and no regional nodal or distant metastases.[4]
  • Epithelioid hemangioendothelioma[5]
  • Large hepatic adenomas

Metabolic disorders

Liver-based metabolic conditions that have been treated with liver transplantation include:[6][7][8]

References

  1. ↑ Ostapowicz G, Fontana RJ, Schiødt FV, Larson A, Davern TJ, Han SH; et al. (2002). "Results of a prospective study of acute liver failure at 17 tertiary care centers in the United States". Ann Intern Med. 137 (12): 947–54. PMID 12484709.
  2. ↑ Martin P, DiMartini A, Feng S, Brown R, Fallon M (2014). "Evaluation for liver transplantation in adults: 2013 practice guideline by the American Association for the Study of Liver Diseases and the American Society of Transplantation". Hepatology. 59 (3): 1144–65. PMID 24716201.
  3. ↑ Eghtesad B, Aucejo F (2014). "Liver transplantation for malignancies". J Gastrointest Cancer. 45 (3): 353–62. doi:10.1007/s12029-014-9590-2. PMID 24604263.
  4. ↑ Longeville JH, de la Hall P, Dolan P, Holt AW, Lillie PE, Williams JA; et al. (1997). "Treatment of a giant haemangioma of the liver with Kasabach-Merritt syndrome by orthotopic liver transplant a case report". HPB Surg. 10 (3): 159–62. PMC 2423854. PMID 9174860.
  5. ↑ Tepetes K, Selby R, Webb M, Madariaga JR, Iwatsuki S, Starzl TE (1995). "Orthotopic liver transplantation for benign hepatic neoplasms". Arch Surg. 130 (2): 153–6. PMID 7848084.
  6. ↑ Carey EJ, Iyer VN, Nelson DR, Nguyen JH, Krowka MJ (2013). "Outcomes for recipients of liver transplantation for alpha-1-antitrypsin deficiency–related cirrhosis". Liver Transpl. 19 (12): 1370–6. doi:10.1002/lt.23744. PMID 24019185.
  7. ↑ Kowdley KV, Brandhagen DJ, Gish RG, Bass NM, Weinstein J, Schilsky ML; et al. (2005). "Survival after liver transplantation in patients with hepatic iron overload: the national hemochromatosis transplant registry". Gastroenterology. 129 (2): 494–503. doi:10.1016/j.gastro.2005.05.004. PMID 16083706.
  8. ↑ Tsuchiya A, Yazaki M, Kametani F, Takei Y, Ikeda S (2008). "Marked regression of abdominal fat amyloid in patients with familial amyloid polyneuropathy during long-term follow-up after liver transplantation". Liver Transpl. 14 (4): 563–70. doi:10.1002/lt.21395. PMID 18383093.
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