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Chapter 51: Liver Transplantation

Amir A. Qamar

ESSENTIAL CONCEPTS

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.

General Considerations

A. Background

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%.

B. Role of UNOS

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).

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).

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INDICATIONS FOR TRANSPLANTATION

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

Table 51–1.Indications for liver transplantation.
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Table 51–1. Indications for liver transplantation.
Common Uncommon

Chronic hepatitis B

Chronic hepatitis C

Autoimmune hepatitis

Alcoholic liver disease

Nonalcoholic fatty liver disease

Primary biliary cirrhosis

Primary sclerosing cholangitis

Hepatocellular carcinoma

Acute liver failure

Hereditary hemochromatosis

Wilson disease

α1-Antitrypsin deficiency

Glycogen storage disease

Tyrosinemia

Urea cycle defects

Amyloidosis

Hyperoxaluria

Branched-chain amino acid disorders

Cystic fibrosis

Alagille syndrome

Progressive familial intrahepatic cholestasis

Polycystic liver disease

Budd-Chiari syndrome

Metastatic neuroendocrine tumor

1. Hepatitis C

The hepatitis C virus (HCV) infects ...

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