Indications and Contraindications for Liver Transplantation According to the Current Guidelines

Abstract

The severity of liver disease is assessed using the MELD (Model of End-Stage Liver Disease) score. Liver transplantation is indicated at MELD ≥ 15 or in MELD < 15 in case of inacceptable quality of life or severe secondary complications from cirrhosis. Besides indications for liver transplantation, contraindications must also be considered in order to avoid futile transplantation, which is defined as 6‑month survival < 60% or 5‑year survival < 50%. Alcoholic cirrhosis is one of the three main indications worldwide with outcomes comparable to other etiologies. Risk factors for alcohol relapse are very well-defined sociodemographic and psychological factors, the 6‑month abstinence period prior to listing is outdated. Liver transplantation for hepatitis C decreased significantly since availability of effective drugs for treatment. Sustained virological response might result in improvement of liver function and even in case of established cirrhosis transplantation might not be necessary (anymore). The decrease in hepatitis C has been accompanied with an increase in non-alcoholic steatohepatitis (NASH). In the context of metabolic syndrome, the cardiovascular risk is increased and in case of severe comorbidities rigorous patient selection is recommended. For malignancies, liver transplantation is restricted to hepatocellular carcinoma (HCC), and when adhering to selection criteria, partly considering biological surrogate markers, outcome is comparable to other indications. The diagnosis of acute or subacute liver failure implies a life-threatening condition; thus, in patients experiencing clinical deterioration with extrahepatic organ failure, transfer to a transplant center is indicated, especially if encephalopathy develops.