Adult Patient Selection
Before final selection and listing for liver transplantation, the prospective candidate undergoes a pretransplant evaluation, which can usually be completed on an outpatient basis over two to three days.
The transplant coordinator and transplant hepatologist are the key individuals who facilitate this evaluation and educate the patient and family members. A comprehensive evaluation is required to determine if absolute or relative contraindications are present and to define the current status of systemic diseases.
All outside medical records and liver biopsy materials are reviewed. Routine evaluation includes hematologic and blood bank studies, complete chemistry profile, viral serology (HBV, HCV, HIV, CMV), chest X-ray, and computed tomography of the abdomen or abdominal ultrasound with examination of blood flow in hepatic vessels. Patients also have routine electrocardiogram and undergo pulmonary function testing if there is a history of lung disease. PPD testing for tuberculosis is routinely performed. Renal function is assessed by creatinine clearance.
Transplant candidates over the age of 60, candidates over the age of 50 with risk factors for coronary artery disease, and patients with a history of cardiac disease undergo cardiology consultation with appropriate cardiac studies, often including stress thallium and/or cardiac catheterization. Doppler of carotid of peripheral vessels may also be appropriate. Consultations with a social worker, financial counselor, and psychiatrist are routine in most centers. Cancer screening with pap smear, mammogram, fecal occult blood testing, and flexible sigmoidoscopy, depending upon age and gender, is completed.
Once the pretransplant evaluation is complete, the patient is presented to the Liver Transplant Selection Committee made up of the entire transplant team, including consultants, for categorization and prioritization. Patients are generally assigned to one of four categories:
- suitable and ready, with listing for a donor organ
- suitable but too well, with placement on inactive status and continued follow-up with the referring physician
- potentially reversible current contraindication, with treatment and recategorization at a later date
- absolute contraindication, with denial of transplantation
Patients who are approved for liver transplantation by the selection committee are then listed for a donor organ with UNOS, and final approval by the insurance carrier or third party payer is sought.