Liver transplantation: When is it necessary?

If you have reached end-stage liver disease, your specialist may recommend that you have a liver transplantation in order to save your life. But just how does your doctor determine whether you are a suitable candidate and what is the long-term outlook for those living with a liver transplant? Fortunately, highly-reputable hepatologist Professor Kevin Moore has answered these questions.

When is a liver transplant necessary?

Liver transplantation is generally carried out for patients with cirrhosis and complications. The main indication for a liver transplant is the development of a number of life-threatening or life-changing complications.  These include recurrent bleeding from the oesophageal or gastric varices (abnormally enlarged veins in the food pipe that connects the throat to the stomach), the development of ascites (a build-up of fluid in the abdomen), or hepatic encephalopathy.

These are all are potentially life-defining events. For example, if you have cirrhosis and develop ascites, then typically you will have a 50 per cent or more mortality in two or three years. If the ascites becomes infected the short and long term prognosis is worse, despite successful treatment of the infection. When a patient develops ascites, they should always be considered for transplantation.

However, if a patient presents with alcohol-related liver disease for the first time with ascites, then stopping alcohol will result in considerable improvement of liver function and counteract the need for a liver transplant.  

What criteria are used to prioritise patients for a liver transplant, or is it simply based on a queuing system with a first come first served basis?

We use biochemical or biomarker criteria to calculate the UK End Stage Liver Disease (UKELD) or the Model of End-Stage Liver Disease (MELD) score. These scoring systems are used to calculate the three to 12-month survival.

These scoring systems that have been validated then revalidated over the years, and are constantly being updated. The MELD score ranges from six to 40 and if, for example, you score over 19, we know you have 40 per cent chance of dying within the next 12 months.

Although the MELD score was originally for short-term mortality, there is enough data to predict 12-month survival.

Patients who are sicker from a liver point of view are prioritised or moved up the list, and those with mild disease moved down.

What is the entire process of liver transplant?

Patients who have developed significant complications from advanced liver disease and with a sufficiently high MELD or UKELD score are assessed in a liver transplant assessment clinic. The assessment determines if there is an:

• Indication for liver transplant and whether it will improve the quality of life and survival
• Whether there are contra-indications to a liver transplant such as co-morbidities, continued alcohol use etc

Generally speaking, the upper age limit for liver transplantation is around 70 years old and beyond that the risks of surgery increase. In terms of improvement, a liver transplant over the age of 70 years is less likely to have a significant impact on life expectancy.

Having decided that you have indications for liver transplant and to improve the quality and duration of your liver, we then have to assess if you are physically fit. We will check to see if you can undertake exercise and that there is no coronary artery disease. Patients who have cirrhosis from fatty liver disease are often diabetic and have risk factors for heart disease. Some of these patients cannot proceed with liver transplantation because of co-existing comorbidities.