Last updated March 15, 2022

Evaluation for Liver Transplantation in Adults

Recommendations and Rationales

1. Evaluation for LT should be considered once a patient with cirrhosis has experienced an index complication such as ascites, hepatic encephalopathy, or variceal hemorrhage or hepatocellular dysfunction results in a MELD Score ≥15. (1-A)
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2. In a liver transplant candidate potentially treatable etiologies and components of hepatic decompensation such as ascites, hepatic encephalopathy, or variceal hemorrhage should be treated. (1-B)
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3. Potential liver transplant candidates with worsening renal dysfunction or other evidence of rapid hepatic decompensation should have prompt evaluation for liver transplant. (2-B)
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4. Obese patients (WHO class 1 and greater) require dietary counseling prior to LT. (1-C)
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5. Class 3 obesity (BMI ≥40) is a relative contraindication to LT. (2-B)
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6. Cardiac evaluation needs to include assessment of cardiac risk factors with stress echocardiography as an initial screening test with cardiac catheterization as clinically indicated. (1-B)
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7. Cardiac revascularization should be considered in LT candidates with significant coronary artery stenosis prior to transplant. (2-C)
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8. In the absence of significant comorbidities, older recipient age (>70 years) is not a contraindication to LT. (2-B)
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9. Portopulmonary hypertension (POPH) should be excluded in LT candidates by routine echocardiography. For RVSP ≥45 mm Hg right heart cardiac catheterization is indicated. (1-B)
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10. Potential recipients with POPH should be evaluated by a pulmonary or cardiac specialist for vasodilator therapy. (1-A)
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11. LT can be offered to potential recipients with POPH, which responds to medical therapy with an MPAP ≤35 mmHg. (1-B)
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12. Hepatopulmonary syndrome (HPS) is relatively common in patients evaluated for LT and should be screened for by pulse oximetry. (1-A)
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13. The presence of severe HPS is associated with increased mortality and affected individuals should undergo expedited LT evaluation. (1-B)
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14. Renal dysfunction requires vigorous evaluation prior to LT to determine etiology and prognosis. (1-A)
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15. Simultaneous liver-kidney transplantation is indicated for LT candidates in whom renal failure reflects CKD with GFR 8 weeks or if extensive glomerulosclerosis is present. (1-B)
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16. Tobacco consumption should be prohibited in LT candidates. (1-A)
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17. LT candidates with a prior extrahepatic malignancy should have received definitive treatment with adequate tumor-free survival prior to listing for LT. (1-B)
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18. Candidates should undergo age and risk factor-appropriate cancer screening, e.g., colonoscopy, mammography, Papanicolaou smear. (1-A)
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19. LT candidates should be screened for bacterial, viral, and fungal infections prior to LT. (1-A)
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20. Treatment for latent TB should be initiated pre-LT. (1-B)
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21. Vaccination should be encouraged against pneumococcus, influenza, diphtheria, pertussis, and tetanus. (1-A)
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22. Live vaccines (mumps, measles, rubella, and varicella), if indicated, should be administered early in the evaluation process. (1-B)
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23. Nutritional assessment should be performed in every LT candidate. (1-A)
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24. Bone densitometry should be obtained as part of transplant evaluation and treatment of osteoporosis initiated prior to LT. (1-A)
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25. Patients with HIV infection are candidates for LT if immune function is adequate and the virus is expected to be undetectable by the time of LT. (1-A)
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26. Patients should be evaluated for and meet reasonable expectations for adherence to medical directives and mental health stability as determined by the psychosocial evaluation. (1-A)
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27. Methadone-maintained patients should not be denied transplantation based on methadone use alone, and expectations of methadone reduction or discontinuation should not be a requirement for transplant listing. (1-B)
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28. Patients should have adequate social/caregiver support to provide the necessary assistance both while waitlisted and until independently functioning in the postoperative period. (1-B)
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29. LT transplant candidates with HCV have the same indications for LT as for other etiologies of cirrhosis. (1-A)
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30. Antiviral therapy pre-LT should be contemplated to reduce the risk of recurrent HCV post-LT. (1-B)
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31. Patients with HBV liver disease should receive antiviral therapy to suppress HBV replication pretransplant and continued surveillance for HCC. (1-A)
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32. LT should be considered in patients with decompensated autoimmune hepatitis who do not respond to or are not appropriate candidates for medical therapies. (1-A)
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33. LT is indicated in autoimmune hepatitis presenting as acute liver failure if recovery is unlikely. (1-B)
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34. LT is indicated for decompensated primary biliary cirrhosis (PBC). (1-A)
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35. Severe pruritus, refractory to medical therapy, may also be an indication for LT. (1-B)
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36. LT is an effective therapy for decompensated liver disease due to primary sclerosing cholangitis (PSC), including bouts of recurrent cholangitis and sepsis. (1-A)
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37. Colonoscopy should be performed annually in patients with PSC and IBD both before and after transplantation due to the high incidence of colorectal cancer. (2-C)
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38. Early referral of alcoholic liver disease (ALD) patients for initiation of LT evaluation facilitates psychosocial assessment and setting addiction treatment goals. (1-A)
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39. Given the chronic nature of alcohol dependence, ongoing monitoring is an important part of a comprehensive treatment plan. (1-B)
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40. Patients with acute liver failure (ALF) require immediate referral to a liver transplant center. (1-A)
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41. Patients with acetaminophen overdose should be evaluated for and meet reasonable expectations for adherence to medical directives and mental health stability as determined by the psychosocial evaluation. (1-A)
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42. LT is an effective therapy for hepatocellular carcinoma (HCC) within the Milan criteria. (1-A)
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43. LT may be an option for HCC in excess of the Milan criteria in combination with tumor downstaging to Milan. (2-C)
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44. Patients diagnosed with early-stage cholangiocarcinoma and deemed unresectable due to parenchymal liver disease or anatomic location may be considered for LT in combination with neoadjuvant chemoradiation. (1-B)
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45. Patients with cholangiocarcinoma who are potential transplant candidates should be expeditiously referred to centers that have established protocols for oncologic assessment and treatment approved by UNOS. (1-B)
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46. LT is an effective therapy for decompensated liver disease due to nonalcoholic steatohepatitis (NASH) or cryptogenic cirrhosis. (1-A)
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47. LT is indicated for decompensated cirrhosis due to α-1-antritrypsin deficiency. (1-A)
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48. Screening to exclude lung disease with pulmonary function tests and chest imaging should be undertaken in patients with α-1-antritrypsin deficiency being evaluated for LT. (1-A)
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49. LT is indicated for decompensated cirrhosis due to hemochromatosis. (1-A)
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50. Iron reduction therapy should be performed prior to LT in candidates with hemochromatosis. (1-B)
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51. Urgent LT is indicated for Wilsonian acute liver failure. (1-A)
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52. LT is indicated in decompensated cirrhosis due to Wilson’s disease unresponsive to medical therapy. (1-A)
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53. LT is not recommended as therapy for neuropsychological Wilson’s disease, as LT does not reliably improve neurologic outcomes. (1-B)
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54. LT should be considered in familial amyloid polyneuropathy (FAP) to eliminate hepatic amyloid production early in the course of disease and particularly prior to the development of cardiac and ocular complications, as these complications are not reliably improved by LT.  (1-B)
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55. Preemptive LT (prior to the development of advanced renal disease) or combined liver and kidney transplantation in the setting of end-stage renal disease (ESRD) are curative for primary hyperoxaluria and should be considered for patients who do not respond to medical therapy. (1-A)
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56. For an LT candidate whose MELD score does not adequately reflect the severity of their liver disease, an appeal for MELD exception points should be made to the Regional Review Boards (RRB). (1-B)
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Recommendation Grading

Overview

Title

Evaluation for Liver Transplantation in Adults

Authoring Organization

Publication Month/Year

March 1, 2014

Document Type

Guideline

External Publication Status

Published

Country of Publication

US

Document Objectives

These recommendations suggest preferred approaches to the diagnostic, therapeutic and preventive aspects of care for liver transplantation in adults

Target Patient Population

Patients requiring liver transplantation

Inclusion Criteria

Female, Male, Adolescent, Adult, Older adult

Health Care Settings

Ambulatory, Hospital, Long term care, Operating and recovery room, Outpatient

Intended Users

Nurse, nurse practitioner, physician, physician assistant

Scope

Diagnosis, Prevention, Management, Treatment

Diseases/Conditions (MeSH)

D008107 - Liver Diseases, D017093 - Liver Failure, D016031 - Liver Transplantation, D008103 - Liver Cirrhosis

Keywords

cirrhosis, liver disease

Source Citation

DOI 10.1002/hep.26972