The Indications for and Timing of Liver Transplantation

Since the 1970s, there has been dramatic growth in the annual number of liver transplants, with improving survival. We review indications for liver transplantation for fulminant hepatic failure (FHF), cholestatic liver disease, and hepatocellular liver disease. A decreased factor V level appears to be a sensitive indicator of FHF requiring transplantation, with a factor V level of less than 20% (less than 30% for age greater than 30 years) suggested as the main indication in encephalopathic patients. The King's criteria are also useful for identifying patients with FHF who require transplantation. FHF from Wilson's disease is universally fatal without transplantation. Any patient with FHF who is unlikely to recover spontaneously should be referred to a transplant center. In patients with primary biliary cirrhosis (PBC), the Mayo Clinic model is widely used to calculate a risk score (based on age, bilirubin, albumin, prothrombin time, and edema). PBC patients with a rapidly rising Mayo risk score and/or a rising bilirubin should be listed for transplantation. The Mayo Clinic survival model for primary sclerosing cholangitis is based on bilirubin, histological stage, age, and presence or absence of splenomegaly, but this model is limited by the emergence of recurrent bacterial cholangitis, dominant strictures, and cholangiocarcinoma. Patients with hepatitis C should be referred for transplantation upon onset of ascites, variceal bleeding, encephalopathy, and/or jaundice with decreasing synthetic function. In patients with autoimmune hepatitis, prognostic indicators that herald the need for transplantation include variceal bleeding, encephalopathy, ascites, hyperbilirubinemia, and worsening synthetic function. Patients with Budd–Chiari syndrome who have end-stage complications of cirrhosis are candidates for transplantation, but clotting disorders must be treated to minimize the risk of recurrent thrombosis. Although hepatocellular carcinoma was once a contraindication, the presence of a small tumor without vascular or distant metastasis is now an indication for liver transplantation. In summary, liver transplantation remains a lifesaving procedure for individuals with end-stage liver disease due to a variety of causes.