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ESSENTIAL CONCEPTS

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ESSENTIAL CONCEPTS

  • Hepatitis C and hepatocellular carcinoma are among the leading indications for liver transplantation in the United States.

  • Thorough medical, psychiatric, and social evaluation is required prior to listing patients for transplantation.

  • The Model for End-Stage Liver Disease (MELD) score is widely used for prioritizing patients on the transplant waiting list.

  • Liver biopsy is needed to confirm the diagnosis of acute rejection, which is common and occurs in up to 60% of patients.

  • Surgical complications generally occur within days to weeks and medical complications months or years later.

  • Biliary strictures and leaks occur in 15% of patients after transplantation.

  • Long-term immunosuppression, with calcineurin inhibitors, is associated with an increased risk of renal failure.

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General Considerations

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A. Background
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Liver transplantation has radically changed the management of patients with chronic liver disease and acute liver failure. Following the first liver transplant procedure in 1963, numerous medical, surgical, and technical breakthroughs were required before transplantation became a viable therapy in liver disease. The 1-year survival rate remained low at 25% until the introduction of cyclosporine as a long-term immunosuppressant in the 1980s. Improvements in patient selection, further refinements in surgical techniques, additional immunosuppressive agents including mycophenolate mofetil, sirolimus, tacrolimus, azathioprine, and effective anti-infective treatment and prophylaxis, have resulted in 5-year survival rates of up to 85–90%.

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B. Role of UNOS
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The United Network for Organ Sharing (UNOS) is a nonprofit scientific organization based in Virginia that is responsible for matching donors to recipients and coordinating the organ transplantation process. UNOS has divided the United States into 11 regions to facilitate organ allocation (Figure 51–1).

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Figure 51–1.

UNOS regions. (Used with permission of United Network for Organ Sharing.)

Note: MELD score = 9.57 × loge creatinine mg per dL + 3.78 × loge bilirubin mg per dL + 11.20 × loge INR + 6.43 (constant for liver disease etiology: 0 = cholestatic or alcoholic; 1 = all other).

Graphic Jump Location
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INDICATIONS FOR TRANSPLANTATION

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There are numerous indications for liver transplantation; common and uncommon indications are listed in Table 51–1.

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Table Graphic Jump Location
Table 51–1.Indications for liver transplantation.
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1. Hepatitis C

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The hepatitis C virus (HCV) infects approximately 170 ...

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