Liver Transplant (cont.)
Who Determines What Patients Receive a Liver Transplant?
Determining whose need is most critical: The United Network for Organ Sharing uses measurements of clinical and laboratory problems to divide patients into groups that determine who is in most critical need of a liver transplant. In early 2002, UNOS enacted a major modification to the way in which people were assigned the need for a liver transplant. Previously, patients awaiting livers were ranked as status 1, 2A, 2B, and 3, according to the severity of their current disease. Although the status 1 listing has remained, all other patients are now classified using the Model for End-Stage Liver Disease (MELD) scoring system
if they are aged 18 years or older, or the Pediatric End-Stage Liver Disease (PELD) scoring system if they are younger than 18 years. These scoring methods were set up so that donor livers could be distributed to those who need them most urgently.
- Status 1 (acute severe disease) is defined as a patient with only recent development of liver disease who is in the intensive care unit of the hospital with a life expectancy without a liver transplant of fewer than 7 days.
- MELD scoring: This system is based on the risk or probability of death within 3 months if the patient does not receive a transplant. The MELD score is calculated based only on laboratory data in order to be as objective as possible. The laboratory values used are a patient's creatinine, bilirubin, and international normalized ratio, or INR (a measure of blood-clotting time). A patient's score can range from 6 to 40. In the event of a liver becoming available to 2 patients with the same MELD score and blood type, time on the waiting list becomes the deciding factor.
- PELD scoring: This system is based on the risk or probability of death within 3 months if the patient does not receive a transplant. The PELD score is calculated based on laboratory data and growth parameters. The laboratory values used are a patient's albumin, bilirubin, and INR (measure of blood-clotting capability). These values are used together with the patient's degree of growth failure to determine a score that can range from 6 to 40. As with the adult system, if a liver were to become available to two similarly sized patients with the same PELD score and blood type, the child who has been on the waiting list the longest will get the liver.
- Based on this system, livers are first offered locally to status 1 patients, then according to patients with the highest MELD or PELD scores. Next, if there are no local recipients, the liver is offered regionally, in the same order, and finally, on a national level.
- Status 7 (inactive) is defined as patients who are considered to be temporarily unsuitable for transplantation.
Who may not be given a liver: A person who needs a liver transplant may not qualify for one because of the following reasons:
- Active alcohol or
substance abuse: Persons with active alcohol or substance abuse problems may continue living the unhealthy lifestyle that contributed to their liver damage. Transplantation would only result in failure of the newly transplanted liver.
- Cancer: Cancers in locations other than just the liver weigh against a transplant.
- Advanced heart and lung disease: These conditions prevent a transplanted liver from surviving.
- Severe infection: Such infections are a threat to a successful procedure.
- Massive liver failure: This type of liver failure
accompanied by associated
brain injury from increased fluid in brain tissue rules against a liver transplant.
- HIV infection
The transplantation team: If a liver transplant is recommended by a primary doctor, the person must also be evaluated by a transplantation team. The usual candidate has advanced liver disease but is otherwise in good health.
- The transplantation team usually consists of a transplant coordinator, a hepatologist (liver specialist), and a transplant surgeon. It may be necessary to see a cardiologist (heart specialist) and pulmonologist (lung specialist), depending on the recipient's age and health problems.
- The potential recipient may also see a psychiatrist because the liver transplantation process may be a very emotional experience that may require life adjustments.
- The liver specialist and the primary doctor manage the person's health issues until the time of transplantation.
- A social worker may be involved in the case. This person assesses and helps develop the patient's support system, a central group of people on whom the patient can depend throughout the transplantation process. A positive support group is very important to a successful outcome. The support group can be instrumental in ensuring that the patient takes all the required medicines, which may have unpleasant side effects. The social worker also checks to see that the recipient is taking medications appropriately.
Robert M McNamara, MD, FAAEM
Francisco Talavera, PharmD, PhD
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