- 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.
- Medical and surgical complications after transplantation can occur immediately or years later.
- Biliary strictures and leaks occur in 15% of patients after transplantation.
- Long-term immunosuppression, particularly with calcineurin inhibitors, is associated with an increased risk of renal failure.
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. Further medical developments in immunosuppression, including mycophenolate mofetil, sirolimus, tacrolimus, and azathioprine, as well as effective anti-infective treatment and prophylaxis, have resulted in 5-year survival rates of up to 85–90%.
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 50–1).
UNOS regions. (Source: 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).
There are numerous indications for liver transplantation; common and uncommon indications are listed in Table 50–1.
Table 50–1. Indications for Liver Transplantation. ||Download (.pdf)
Table 50–1. Indications for Liver Transplantation.
Chronic hepatitis B
Chronic hepatitis C
Alcoholic liver disease
Nonalcoholic fatty liver disease
Primary biliary cirrhosis
Primary sclerosing cholangitis
Acute liver failure
Glycogen storage disease
Urea cycle defects
Branched-chain amino acid disorders
Progressive familial intrahepatic cholestasis
Polycystic liver disease
Metastatic neuroendocrine tumor
The hepatitis C virus (HCV) infects approximately 170 million people worldwide and up to 4 million people (1–1.5%) in the United States. Based on histopathologic studies, it is believed that 5–20% of patients with hepatitis C develop cirrhosis after 20 years of ...