![]() ![]() Once a non-urgent patient is listed, the prioritization and allocation policies, together with clinical management which is critical to avoid temporary or permanent delisting, influence LT timing. With regard to waiting list priority, patients with ALF have the highest priority and are on a separate urgent waiting list. The decision not to list a patient can either be permanent or, if the disease is not advanced enough, temporary and the patient should enter a follow-up program. The decision of whether a patient is an appropriate candidate for LT is based on the evaluation of many factors other than the presence of liver disease and liver failure and is established by a “multidisciplinary transplant team”. Relative contraindication can cause patient exclusion when more than one is present in the same patient. The presence of one or more absolute contraindication imposes patient exclusion from listing. These can change between centers and over the years. Table Table2 2 shows the contraindications to LT. The aims of this selection are: (1) to ascertain that the severity of liver disease is sufficient to predict a short-term mortality risk that is lower with, than without, transplantation and (2) to exclude patients with contraindications. Finally, referral for patients with less common metabolic disorders and other miscellaneous diseases should be decided case by case, based on the severity of extrahepatic morbidity and/or liver-related complications.īecause of the gap between the number of patients that need a transplant and the number of deceased donors available, and considering that more than 2000 candidates in United States die each year while awaiting transplantation, once a patient has been referred, strict selection criteria are applied. ![]() ![]() With regard to patients with cirrhosis, referral should generally occur at the moment of any complication, such as synthetic dysfunction, hepatic encephalopathy, ascites, hepatocellular carcinoma (HCC), hepatorenal syndrome, variceal or other portal hypertensive bleeding, hepatopulmonary syndrome, portopulmonary hypertension and conditions that impair quality of life (i.e., recurrent cholangitis, intractable pruritus, malnutrition, hepatic myelopathy). ![]() Because of the unpredictable and often fast evolution of acute liver failure (ALF), patients with any severe acute hepatitis should be hospitalized where a transplant center is available. Table Table1 1 shows the general indications for primary LT in adults. Missing or late referral leading to limited access to surgery should be avoided. In fact, in Europe, ten years patient survival after LT performed in adults from 1988 to 2010 is 55%.Īccess to LT at the appropriate timing depends on a three step process: (1) referral to a transplant center (2) listing after careful evaluation by the transplant team and (3) medical management, prioritization and allocation policy on the waiting list.Įvery physician should know the appropriate timing to refer a patient with liver disease to a transplant center to give the same chances to every patient and access the best treatment available. Liver transplantation (LT) represents the best treatment option for end-stage liver disease and liver-based metabolic conditions causing systemic disease. These two variables are known to determine the “transplant benefit” (i.e., when the expected patient survival is better with, than without, transplantation) and should guide donor allocation. Thus, the appropriate timing of transplantation depends on recipient disease severity and, although this is still a matter of debate, also on donor quality. Patients approved for transplantation are placed on the transplant waiting list and prioritized according to disease severity. However, because of the shortage of organ donors and the short-term mortality after liver transplantation on one hand and the possibility of managing the complications of cirrhosis with other treatments on the other, patients are carefully selected by the transplant center to ensure that transplantation is indicated and that there are no medical, surgical and psychological contraindications. Referral to a transplant center should be considered when at least one complication of cirrhosis occurs during its natural history. Early referral to a transplant center is crucial in acute liver failure due to the high mortality with medical therapy and its unpredictable evolution. Liver transplantation is indicated in patients with acute liver failure, decompensated cirrhosis, hepatocellular carcinoma and rare liver-based genetic defects that trigger damage of other organs. ![]()
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