Liver Transplant Information
The goal of the Liver Transplant Program at California Pacific Medical Center is to provide liver transplantation to those patients who will obtain maximum benefit from the procedure. This includes patients who are estimated to have less than two years of life and have no alternative medical or surgical therapies. The liver transplant procedure must be likely to prolong the patient's life for at least five years and/or to restore the patient to a normal or near normal functional status. Thus, the overall goals of liver transplantation are to prolong life and improve the quality of life. If you are interested in scheduling a liver transplant evaluation, contact our referral line at (415) 600-3742.
- Indications for Transplant
- Patient Selection Criteria for Liver Transplantation
- Contraindications to Transplant
- Evaluation Process
- Selection Committee
- Special Circumstances
Indications for Transplant
A selection committee composed of transplant surgeons, hepatologists, nurse coordinators, psychiatrists, social workers, dietitians and other interested individuals meets weekly to determine the suitability of potential liver transplant candidates and determine the timing and priority for transplantation. General indications for liver transplantation are as follows:
- Irreversible cirrhosis with at least two signs of liver insufficiency
- Fulminant hepatic failure: coma Grade 2
- Unresectable hepatic malignancy confined to the liver that is less than 5 cm. in diameter
- Metabolic liver disease that would benefit from liver replacement
- MELD score of 15 or higher
Other specific indications for liver transplantation include: Budd-Chiari Syndrome, benign hepatic tumors, and autoimmune liver diseases. In addition, there should be no alternative forms of therapy and no contraindications for the procedure. Finally, the patient and family members should be able to accept the procedure and provide for its costs.
The most common indication for liver transplantation is end-stage chronic liver disease, accounting for approximately two-thirds of all patients. General clinical and biochemical indications for liver transplantation in patients with chronic cholestatic liver diseases (e.g., primary biliary cirrhosis and primary sclerosing cholangitis) include:
- Serum bilirubin > 8-10 mg/dL
- Intractable pruritus
- Intractable bone disease
- Malnutrition or recurrent bacterial cholangitis
- Severe or intractable encephalopathy
In patients with chronic hepatocellular diseases (e.g., chronic hepatitis with cirrhosis), general biochemical indications for liver transplantation include:
- Serum albumin < 3.5 g/dL
- Prothrombin time > 3 seconds above control or INR > 1.3
- Bilirubin > 2 mg/dL
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Patient Selection Criteria for Liver Transplantation
In both categories of liver diseases, factors that are listed below are often the precipitating reason for proceeding with liver transplantation:
- Severe fatigue
- Unacceptable quality of life
- Recurrent variceal bleeding
- Intractable ascites
- Recurrent or severe hepatic encephalopathy
- Spontaneous bacterial peritonitis
- Hepatorenal syndrome
- Development of small hepatocellular carcinoma on hepatic imaging
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Contraindications to Transplant
Contraindications to liver transplantation can be divided into those that are absolute and those that are relative, i.e., are expected to complicate and increase the risk of transplantation. Absolute contraindications to liver transplantation include:
- AIDS or HIV positivity
- Irreversible brain damage
- Multi-system failure that is not correctable by liver transplantation
- Malignancy outside the liver (not skin cancer)
- Infection outside the hepatobiliary system
- Active alcohol or substance abuse
- Advanced cardiopulmonary or other systemic disease
Factors that increase the risk of liver transplantation include the following:
- Advanced age
- Advanced chronic renal failure
- Chronic hepatitis B virus infection
- Hepatocellular carcinoma
- Hypoxemia from intrapulmonary shunts
- Massive ascites
- Portal vein thrombosis
- Prior portosystemic shunt surgery
- Prior biliary tract surgery
- Severe malnutrition
- Severe abdominal atherosclerosis
California Pacific's selection committee uses the above general principles as well as prognostic indices that are under development for conditions such as fulminant hepatic failure, primary biliary cirrhosis and primary sclerosing cholangitis. Early referral for preoperative evaluation for liver transplantation is critical and allows evaluation before the development of multiple or advanced complications, which decrease the survival and increase the costs of liver transplantation. Early referral allows close follow-up of patients with end-stage liver disease with the referring physician and an adjustment of priority status for transplantation. In addition, the family members and patient have ongoing education regarding the liver transplant process.
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The majority of pre-transplant evaluations can be completed on an outpatient basis over a two- to three-day period. Candidates for transplantation are typically seen by the transplant surgeon, transplant hepatologist, transplant nurse coordinator, psychiatrist, social worker, nutritionist/dietitian, financial counselor and other consultants as appropriate. (Consultations/consults for cardiology, pulmonary, oncology, etc. are performed by specialty physicians at California Pacific who have expertise in working with patients with end-stage liver disease and organ complications/interactions from other systems. These consultations by our physicians are necessary for subsequent patient listing and transplantation.) The transplant coordinator is the key contact person who facilitates the pre-transplant evaluation.
Patients who are referred to California Pacific undergo a thorough evaluation that consists of review of past medical and surgical history and review of any previous liver biopsies or other diagnostic tests, particularly radiologic examinations. Routine laboratory and X-ray evaluation include hematologic and blood banking studies, complete chemistry profile, viral serology (hepatitis B and C, HIV, CMV), chest X-ray, computed tomography of the abdomen for estimate of liver volume and for hepatic abnormality screening, as well as Doppler ultrasound of hepatic vessels. These tests must be performed at California Pacific due to our expertise in evaluating patients with ESLD and liver transplantation. The vascular anatomy must be well defined for optimal transplant outcomes. PPD testing for tuberculosis is routinely performed. Renal function is assessed by creatinine clearance (evaluation of substance found in urine).
Transplant candidates over the age of 55-60 years or candidates over the age of 50 with risk factors for coronary disease, or those with a history of cardiac disease, undergo cardiology consultation with appropriate cardiac studies often including stress thallium and/or cardiac catheterization. Doppler of carotid or peripheral vessels may also be appropriate. Cancer screening as recommended by the American Cancer Society (Pap smear, mammogram, fecal occult blood testing, and flexible sigmoidoscopy depending upon age/gender), is completed.
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Once the pre-transplant evaluation is completed, the patient’s profile is presented to the selection committee for categorization and prioritization. Patients are generally assigned to one of two categories:
- List for transplant: Patient receives a letter stating the follow-up needed to get and stay on the transplant list
- Declined for transplant: Patient receives a letter stating what he/she needs to complete to be reconsidered for transplant listing
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There are a number of specific indications and/or circumstances regarding liver transplantation that undergo special scrutiny. One of these conditions is alcoholic cirrhosis. California Pacific's experience, as well as that of other transplant centers, has indicated that properly selected patients with alcoholic cirrhosis experience excellent survival and good quality of life following liver transplantation. All patients referred to California Pacific Medical Center undergo careful evaluation by a hepatologist, psychiatrist and social worker with attention to indicators for continued sobriety and compliance with the post-transplant long-term follow up. In particular, previous social stability, employment record, psychiatric status and length of sobriety are evaluated. For patients with the diagnosis of alcohol dependence or abuse, the referring physician will ask the patient to sign an alcohol contract and participate in alcohol recovery while awaiting transplantation. Only patients having psychosocial factors predicting long-term sobriety are accepted for transplantation.
Patients who have chronic hepatitis B virus (HBV) infection are a subset of patients who present a special problem because of recurrent infection of the transplanted organ. Based on encouraging results from a number of European and U.S. centers, we are currently treating all patients with hepatitis B immune globulin (HBIG) and lamivudine post-transplant in an attempt to reduce the reinfection rate in the allograft (now less than 10%). We are currently accepting patients with chronic HBV infection who are either HBeAg/HBV DNA negative as well as those who are HBeAg/HBV DNA positive. We also use lower doses of immunosuppressive medications post-transplant in hopes of reducing clinically significant HBV infection.
Older patients also undergo special scrutiny. Our center and others have reported excellent results in patients over age 60. All candidates referred for liver transplantation past the age of 60 undergo particularly thorough evaluation, with particular attention to silent coronary or vascular disease. If patients have no other major organ disease and are expected to live five or more years, they are typically approved for transplantation.
Finally, patients with hepatocellular carcinoma undergo special scrutiny and adjunctive therapy. They have a long-term survival after liver transplantation, which is less than patients undergoing transplantation for other indications. In order to improve upon these results, we currently offer adjuvant therapy in the form of chemo-embolization or chemotherapy to control the spread of cancer cells or unrecognized micrometastases. All patients undergo thorough evaluation for identifiable malignancy outside of the liver, including chest CT scan, abdominal and pelvic CT scan and bone scan. Finally, the abdominal cavity is explored carefully at the time of transplantation before proceeding with the hepatectomy and transplantation.
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All patients are followed for life with maintenance of master records in the Liver Transplant Program at California Pacific Medical Center. Regular communication by liver transplant coordinators or transplant physicians with patients and referring doctors is implemented to enhance the optimal long-term results. Hepatologists visit satellite clinics in selected Northern California and Nevada cities to facilitate the appropriate timing of referral and liver post-transplant follow-up.
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