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Referral Checklist

Referral Form

Pre-Liver Transplant Evaluation Protocol

All patients referred for Liver Transplant Evaluation will be reviewed by the nurse coordinator.

If any of the following exist, the patient will be scheduled for a Hepatology consult and Liver Transplant Surgery consult only:

• Use of alcohol or drugs in the last 6 months
• Significant comorbid medical history
• History of cancer in the previous two years
• MELD score below 7
• Ideal Body Weight greater than 150%
• Age of patient greater than 75 years old

Coordinators may discuss any case with Hepatologist or Liver Transplant Surgeon prior to scheduling to determine appropriate tests.

Transplant Eligibility Criteria

• End-stage liver disease
• Absence of serious systemic illness or other medical conditions that may affect immediate or long-term survival.
• Full understanding of transplant procedure, its limitations and long-term compliance to follow-up requirements.
• Strong social support network.
• Free from active drug, nicotine or alcohol abuse.
• Weight less than 150% of IBW.

Patients who do not meet the above criteria at the time of referral will be given the opportunity to fulfill these criteria and undergo re-evaluation. Formal input from the psychiatry staff is required to assess the risk of return to alcohol use following liver transplantation.

Indications for Liver Transplant

• Presence of irreversible liver disease and a life expectancy of less than 12 months with no effective medical or surgical alternatives to transplantation
• Chronic liver disease that has progressed to the point of significant interference with the patient's ability to work or with his/her quality of life
• Progression of liver disease that will predictably result in mortality exceeding that of transplantation (85% one-year patient survival and 70% five-year survival)
• Cholestatic Diseases: primary biliary cirrhosis, sclerosing cholangitis, secondary biliary cirrhosis, biliary atresia, cystic fibrosis
• Chronic Hepatitis: hepatitis B, hepatitis C, hepatitis D, autoimmune chronic active hepatitis, cryptogenic cirrhosis, chronic drug toxicity or toxin exposure
• Alcoholic Cirrhosis: Patients with alcoholic cirrhosis are considered for transplant if they meet current criteria for abstinence and rehabilitation.
• Metabolic Diseases: hemochromatosis, Wilson's disease, Alpha-1-antitrypsin deficiency, glycogen storage disease, tyrosinemia, familial amyloidotic polyneuropathy, other metabolic disorders treatable by liver replacement.
• Fulminant Acute Hepatic Necrosis: viral hepatitis, drug toxicity, toxin, Wilson's disease.
• Primary Hepatic Tumors: selected patients with hepatocellular carcinoma

Manifestations of End-Stage Liver Disease

• Progressive jaundice
• Intractable ascites
• Spontaneous bacterial peritonitis
• Hepatorenal Syndrome
• Encephalopathy
• Variceal bleeding
• Intractable pruritus
• Chronic fatigue (such as resulting in loss of gainful employment)
• Bleeding diathesis or coagulopathy

Cholestatic liver disease

• Serum albumin < 3.0 g/dL
• Intractable pruritus
• Progressive bone disease
• Recurrent bacterial cholangitis

Hepatocellular liver disease

• Serum albumin in < 3.0 g/d L
• Prothrombin time >3 seconds above control

Both cholestatic and hepatocellular liver disease

• Recurrent or severe hepatic encephalopathy
• Refractory ascites
• Spontaneous bacterial peritonitis
• Recurrent portal hypertensive bleeding
• Severe chronic fatigue and weakness
• Progressive malnutrition
• Development of hepatorenal syndrome
• Detection of small, coincidental hepatocellular carcinoma

Factors which place individual at highest risk for poor outcome, poor quality of life or increased mortality

If your doctor thinks you might need a liver transplant, then you should do everything you can to keep healthy and strong. Some of the things that might prevent you from getting a liver transplant include:

• Continuing to use alcohol or illegal drugs
• Being at high risk of using drugs or alcohol again after the surgery
• Being unable to follow your doctor's instructions, like taking your medicine when you are supposed to
• Having too little support from people at home to care for you after the operation
• Having advanced cancer of the liver
• Having another kind of cancer in the past 3 to 5 years
• Having severe heart, lung or kidney disease
• Having advanced HIV disease (AIDS)
• Severe hardening of the arteries
• Systemic infections

Factors which place individual at higher risk for poor outcome,
poor quality of life or increased mortality

• Obesity (>150% of IBW).
• Active systemic illness that would limit long-term survival.
• Previous extra hepatic malignancies
• Prior portosystemic shunts
• Malnutrition