General Principles

• Liver transplantation is an effective therapeutic option for irreversible acute liver disease and ESLD for which available therapies have failed. Whole cadaveric livers and partial livers (split-liver, reduced-size, and living-related) are used in the US as sources for liver transplantation. There continues to be a disparity between supply and demand of suitable livers for transplantation.
• The Model for End-Stage Liver Disease (MELD) score allows for prioritization for liver transplantation. It is calculated by a formula that takes into account serum bilirubin, serum creatinine, and INR. Patients are regularly evaluated for a liver transplantation when they achieve a MELD of 15. Patients are considered for “exception MELD points” for conditions such as HCC within Milan criteria, hepatopulmonary syndrome, portopulmonary hypertension, polycystic liver disease, familial amyloidosis, small unresectable hilar cholangiocarcinoma, and unusual tumors.
• Sodium has been incorporated to MELD to increase priority for organ allocation.
• Patients with cirrhosis should be considered for transplant evaluation when they have a decline in hepatic synthetic or excretory functions, ascites, hepatic encephalopathy, or complications such as HRS, HCC, recurrent SBP, or variceal bleeding.
• Candidates for liver transplantation are evaluated by a multidisciplinary team that includes hepatologists, transplant surgeons, transplant nurse coordinators, social workers, psychologists, and financial coordinators.
• General contraindications to liver transplant include severe and uncontrolled extrahepatic infection, advanced cardiac or pulmonary disease, extrahepatic malignancy, multiorgan failure, unresolved psychosocial issues, medical noncompliance issues, and ongoing substance abuse (e.g., alcohol and illegal drugs).